UNIVERSITY  OF  CALIFORNIA 

COLLEGE  OF  MEDICINE 


1   8 
IRVINE  6AUF6RNIA  I2S84 


e-= 


PHYSICAL  DIAGNOSIS 


BY\I/ 

RICHARD  C.  CABOT,  M.D. 

ASSISTANT    PROFESSOR    OF    MEDICINE    IX    HARVARD    UNIVERSITY 


ffourtb  EMtion,  TRexnsefc  anfc  Enlarged 


WITH    FIVE    PLATES,   AND    TWO    HUNDRED    AND    FORTY    FIGURES 
IN    THE    TEXT 


NEW    YORK 
WILLIAM    WOOD    AND    COMPANY 

MDCCCCIX 


COPYRIGHT,  1909, 
By   WILLIAM    WOOD    AND  COMPANY. 


FEEDEEICK   G.   SHATTUCK,   M.D. 

Jackson  Professor  of  Clinical  Medicine 
in  Harvard  University 

IN    EVIDENCE   OF    MY   APPRECIATION   OP 

THE   EXAMPLE   OF   SINCERITY,    COMMON   SENSE,    AND   ENTHUSIASM 

ESTABLISHED   BY   HIM   IN   THE   TEACHING   AND 

THE   PRACTICE    OP   MEDICINE 


PREFACE  TO  THE  FOURTH  EDITION. 


A  GOOD  many  small  changes  have  been  made,  most  of  them  em- 
bodying criticisms  suggested  by  those  who  were  good  enough  to 
read  the  book  with  care. 

The  most  important  changes  concern  the  use  of  the  free  ear  in 
auscultation,  the  discussion  of  Bronchiectasis  and  the  differences 
between  the  t\vo  sides  of  the  normal  chest.  Some  of  the  pictures 
have  been  changed,  and  I  hope  improved. 

15)0  MAHLBOHOUGH  STREET, 
BOSTON,  June,  1909. 


PREFACE. 


THIS  book  endeavors,  to  present  an  account  of  the  diagnostic 
methods  and  processes  needed  by  competent  practitioners  of  the 
present  date.  It  differs  from  other  books  on  the  subject  in  that  it 
makes  no  attempt  to  describe  technical  processes  with  which  the 
writer  has  no  personal  familiarity  and  gives  no  space  to  the  descrip- 
tion of  tests  which  he  believes  to  be  useless. 

To  gain  genuine  familiarity  with  all  the  technical  processes  de- 
scribed in  most  books  on  physical  diagnosis — such  familiarity  as 
makes  one  competent  to  use  them  with  due  regard  for  the  sources 
and  limits  of  error  inherent  in  them — needs  more  than  the  life-time 
of  one  man.  But  unless  one  has  one's  self  used  a  technical  process 
long  enough  to  gain  this  sort  of  mastery  over  it,  one  cannot  prop- 
erly describe  it,  far  less  recommend  it  to  others.  Because  of  my  lack 
of  personal  acquaintance  with  such  methods  as  cystoscopy,  ophthal- 
moscopy,  and  laryngoscopy  I  have  attempted  no  description  of  them, 
although  I  believe  they  should  sooner  or  later  be  mastered  by  every 
internist.  All  that  I  have  described  I  know  by  prolonged  use. 

A  book  constructed  on  this  basis  should  make  obvious  what  its 
writer  considers  important  and  what  unimportant,  and  reveal 
therein  not  only  his  opinions  but  his  personal  limitations.  But  I 
believe  there  is  no  longer  a  demand  for  books  that  attempt  impar- 
tially to  present  all  that  lias  been  or  is  now  thought  of  value  by 
some  one.  The  personal  equation  cannot  and  should  not  be  ig- 
nored. In  diagnosis  as  in  therapeutics  "  What  do  you  find  valua- 
ble ?  "  is  the  question  that  our  contemporaries  ask  of  any  one  of  us, 
not  "  What  has  been  recommended  ?  " 

In  the  endeavor  further  to  break  down  the  false  distinction  be- 


VI  PREFACE. 

tween  clinical  diagnosis  and  laboratory  diagnosis  I  have  described 
all  the  methods  of  getting  at  an  organ — e.y.,  the  kidney — in  a  sin- 
gle section.  Palpation,  thermometry,  nrinalysis  are  different  proc- 
esses by  which  we  may  gather  information  about  the  kidney.  The 
student  should  be  accustomed  to  think  of  them  and  practise  them 
in  close  sequence. 

For  the  same  reason  the  most  important  methods  of  investigat- 
ing the  stomach  have  been  grouped  together  without  any  distinction 
of  "clinical"  and  "laboratory"  procedure. 

For  the  illustrations  I  owe  many  thanks  to  many  persons,  espe- 
cially to  Drs.  Frank  Billings,  A.  E.  Boycott,  E.  II.  Bradford,  E. 
11.  Carson,  J.  Everett  Dutton,  E.  T.  Edes,  Joel  E.  Goldthwait, 
J.  S.  Haldane,  Frederick  T.  Lord,  R.  \V.  Lovett,  H.  C.  Masland, 
S.  J.  Meltzer,  Percy  Musgrave,  R.  F.  O'Neil,  J.  E.  Schadle,  Will- 
iam H.  Smith,  W.  S.  Thayer,  and  G.  L.  Walton ;  also  to  the  edi- 
tors of  the  Boston  Medical  and  Siiraical  Journal,  the  St.  Paul 
Medical  Journal,  American  Medicine,  The  Journal  of  Experimental 
Medicine,  and  The  Lancet. 

My  assistant,  Dr.  Mary  W.  Rowley,  has  helped  me  very  much 
with  the  index  as  well  as  with  other  parts  of  the  book. 

190  MARLBORO  ST.,  BOSTON. 
June,  1305. 


TABLE  OF  CONTENTS. 


CHAPTER   I. 
DATA  RELATING   TO   THE  BODY   AS   A   WHOLE. 

PAGE 

1     WKIGHT, 1 

(a)  Causes  of  Gain  in  Weight,  .......       1" 

(b)  Causes  of  Loss  in  Weight 2 

2.  TEMPERATURE — TECHNIQUE  AND  SOURCES  OF  ERROR,        ...      2 

(a)  Causes  of  Fever 2 

(b)  Types  of  Fever, 2 

(e)  Subnormal  Temperature, .2 

(d)  Chills  and  Their  Causes 2,  3 


CHAPTER   II. 
THE    HEAD,    FACE,    AXD   XECK. 

I.  The  Cranial  Vault 5 

1.  Size,  Shape, 5 

2.  Fontanels, 6 

3.  Hair,            7 

II.  The  Forehead 8 

III.  The  Face  as  a  Whole 9 

IV.  Movements  of  the  Head  and  Face, 13 

V.  The  Eyes 13 

(it)  Ocular  Motion,           16 

(b)  The  Retina, 16 

VI.  The  Nose '       .  17 

VII.  The  Lips 18 

VIII.  The  Teeth, 20 

IX.  The  Breath, 21 

X.  The  Tongue, 22 


Vlll  TABLE  OF  CONTENTS. 

PAGE 

XI.  The  Gums 24 

XII.  The  Buccal  Cavity 25 

XIII.  The  Tonsils  and  Pharynx, 26 

XIV.  The  Neck 29 

(a)  Glands, 29 

(b)  Abscess  or  Scars <H 

(c)  Tumors  and  Cysts, .        31-34 

(d)  Vertebral  Tuberculosis 33 

(e)  Actinomycosis,  34 

(/)  Cervical  Rib .34 


CHAPTER   III. 

THE   ARMS   AND   HANDS;  THE    BACK. 

THE  ARMS. 

I.  Paralysis, .  35 

II.  Wasting  of  One  Arm, 37 

III.  Contractures,  37 

IV.  (Edema, 38 

V.  Tumors 38 

VI.  Miscellaneous  Lesions  of  the  Forearm,     T~ 40 

THE  HANDS, 41 

I.  Evidence  of  Occupation 41 

II.  Temperature  and  Moisture, 42 

III.  Movements, 42 

IV.  Deformities, 46 

THE  NAILS 52 

THE  BACK 53 

I.  Stiff  Back, 53 

II.  Sacro-iliac  Disease, 53 

III.  Spinal  Curvature, 54 

IV.  Tumors  of  the  Back, 54 

V.  Prominent  Scapula 55 

VI.  Spina  Biflda, 55 


TABLE  OF  CONTENTS.  ix 

CHAPTER    IV. 

THE    CHEST. 

TECHNIQUE   AND    GENERAL   DIAGNOSIS. 

PAGE 

INTRODUCTION, 56 

I.  Methods  of  Examining  the  Thoracic  Organs,    .        .        .        ...  56 

II.  Regional  Anatomy  of  the  Chest, 56 

INSPECTION. 

I.  SIZE 60 

II.  SHAPE •      ...  61 

(a)  The  Rachitic  Chest 62 

(b)  The  Paralytic  Chest 63 

(c)  The  Barrel  Chest, 64 

III.  DEFORMITIES,     . .66 

(a)  Curvature  of  the  Spine 66 

(b)  Flattening  of  One  Side  of  the  Chest 66 

(e)  Prominence  of  One  Side  of  the  Chest, 67 

(d)  Local  Prominences, 68 

IV.  RESPIRATORY  MOVEMENTS 69 

(a)  Normal  Respiration, 69 

(b)  Anomalies  of  Expansion, 69 

1.  Diminished  Expansion 70 

2.  Increased  Expansion, .71 

(c)  Dyspnoea 71 

V.  THE  RESPIRATORY  RHYTHM 74 

(a)  Asthmatic  Breathing, 74 

(b)  Cheyne-Stokes  Breathing 74 

(c)  Restrained  Breathing, 75 

(d)  Shallow  and  Irregular  Breathing, 75 

(e}  Stridulous  Breathing, 76 

VI.  DIAPHRAGMATIC  MOVEMENTS  (Litten's  Phenomenon),      .        .        .76 

VII.  THE  CARDIAC  MOVEMENTS 79 

1.  Normal  Cardiac  Impulse, 79 

2.  Displacement  of  the  Cardiac  Impulse 82 

3.  Apex  Retraction. 84 

t.  Epigastric'  Pulsation, 85 

5.    Uncovering  of  the  Heart 85 


X  TABLE  OF  CONTENTS. 

PAGE 

VIII.  ANEURISM  AND   OTHER  CAUSES  OF  ABNORMAL,  PULSATIONS   OP 

THE  CHEST  WALL, 86 

IX.  THE  PERIPHERAL  VESSELS 87 

(a)  Venous  Phenomena,  .  88 

(b)  Arterial  Phenomena, 89 

(c)  Capillary  Phenomena, 91 

X.  THE  SKIN  AND  Mucous  MEMBRANES, 92 

1.  Cyanosis, ,        .        .        .92 

2.  (Edema, ' 93 

3.  Pallor, 93 

4.  Jaundice, 93 

5.  Scars  and  Eruptions,  .        *      \        •        •        •        •        •        .94 
XI.  ENLARGED  GLANDS , 94 

CHAPTER    V. 
PALPATION  AND   STUDY   OF  THE   PULSE. 

I.  PALPATION,    .        .        .        . 96 

1.  The  Cardiac  Impulse, 96 

2.  Thrills 97 

3.  Tactile  Premitus, 98 

4.  Friction,  Pleural  or  Pericardial, 99 

5.  Palpable  Rales,  .        . 101 

6.  Tender  Points, 102 

7.  Abnormal  Pulsations, .        .  102 

8.  Tumors 102 

9.  Temperature  and  Quality  of  the  Skin, 103 

II.  THE  PULSE,          • ...  103 

1.  The  Rate,    ,        .        . 105 

2.  Rhythm I0r> 

3.  Compressibility 106 

4.  Size  and  Shape  of  Pulse  Wave,          .......  106 

5.  Tension,       . 108 

6.  Size  and  Position  of  Artery, 109 

7.  Condition  of  Artery  Walls, 110 

III.  ARTERIAL  PRESSURE  AND  THE  INSTRUMENTS  FOR  MEASURING  IT,    111 

1.  Gaertner's  Tonometer, ,        .        .112 

2.  The  Riva-Rocci  Instrument 113 

3.  The  Instrument  of  Hill  and  Barnard, 114 

4.  The  Oliver  Instrument,  .  115 


TABLE  OF  CONTENTS.  XI 

CHAPTER  VI. 
PERCUSSION. 

PAGE 

I.  TECHNIQUE,  .......  ....  118 

,  .    \  Mediate  Percussion  ........       )    ...g 

I  '    '/  Immediate  Percussion,  ......       j 

(b)  Auscultatory  Percussion  .........  125 

(c)  Palpatory  Percussion  .........  127 

II.  PERCUSSION-RESONANCE  OF  THE  NORMAL  CHEST,     ....  127 

(a)  Vesicular  Resonance,         .        .......  128 

(6)  Dulness  and  Flatness,         .         .......  129 

(c)  Tympanitic  Resonance,      ........  130 

(d)  Cracked-pot  Resonance,     .         .......  134 

(e)  Amphoric  Resonance,         ........  135 

(/)  The  Lung  Reflex,      .........  136 

III.  SENSE  OF  RESISTANCE,         .        ........  136 


CHAPTER    VII. 
AUSCULTATION. 

1.  MEDIATE  AND  IMMEDIATE  AUSCULTATION  .......  137 

2.  SELECTION  OF  A  STETHOSCOPE,       ........  138 

3.  THE  USE  OF  THE  STETHOSCOPE,      ........  143 

A.  Selective  Attention  and  What  to  Disregard,    .....  143 

B.  Muscle  Sounds,          ..........  146 

C.  Other  Sources  of  Error,     .........  147 

•\.  AUSCULTATION  OF  THE  LUNGS,       ........  149 

I.  Respiratory  Types  ...........  150 

(«)  Vesicular  Breathing,  .......  151 

(b)  Tubular  Breathing,     ........  153 

(c)  Broncho-vesicular  Breathing  .......  154 

(rf)  Emphysematous  Breathing,       .....         .  155 

(e)  Asthmatic  Breathing,          .......  155 

(/)  Cog-wheel  Breathing,        .......  156 

(g)  Amphoric  Breathing,          .......  156 

(k)  Metamorphosing  Breathing,       ......   15(i 

II.  Differences  between  the  Right  and  the  Left  Chest,         .         .        .  157 


xii  TABLE  OF  CONTENTS. 

PAGE 

III.  Pathological  Modifications  of  Vesicular  Breathing,       .        .        .  157 

(a)  Exaggerated  Vesicular  Breathing, 157 

(b)  Diminished  Vesicular  Breathing, 158 

IV.  Bronchial  Breathing  in  Disease,      ..,...".  160 
V.  Broncho-vesicular  Breathing  in  Disease, 160 

VI.  Amphoric  Breathing 161 

VII.  RSles, 161 

(a)  Moist, 161 

(b)  Dry 162 

(c)  Musical, 164 

VIII.  Cough.     Effects  on  Respiratory  Sounds, 165 

IX.  Pleural  Friction, 165 

X.  Auscultation  of  the  Voice  Sound 167 

(«)  The  Whispered  Voice,         .        .        .       • .        .        .        .167 

(b)  The  Spoken  Voice, 168 

(c)  Egophony, 169 

XI.  Phenomena  Peculiar  to  Pneumo-hydrothorax,       ....  169 

(a)  Succussion, 169 

(b)  Metallic  Tinkle .       .        .        .170 

(c)  The  Lung  Fistula  Sound, 170 


CHAPTER   VIII. 
AUSCULTATION   OF   THE   HEART. 

1.  THE  VALVE  AREAS, 171 

2.  NORMAL  HEART  SOUNDS,        .        r  172 

3.  MODIFICATIONS  IN  THE  INTENSITY  OF  THE  HEART  SOUNDS,        .        .  174 

(a)  Mitral  First  Sound, 175 

1.  Lengthening, 175 

2.  Shortening,          . 175 

3.  Doubling, 176 

(b)  The  Second  Sounds  at  the  Base  of  the  Heart 176 

1.  Physiological  Variations 176 

2.  Pathological  Variations 178 

(a)  Accentuation  of  Pulmonic  Second  Sound,          .         .         .  178 

(b)  Weakening  of  Pulmonic  Second  Sound 179 

(c)  Accentuation  of  the  Aortic  Second  Sound,         .        .        .179 

(d)  Weakening  of  the  Aortic  Second  Sound,  ....  179 

(e)  Accentuation  of  Both  Second  Sounds,        ....  180 
(/)  Summary, 180 


TABLE  OF  CONTENTS.  Xlll 

PAGE 

(c)  Modifications  in   Rhythm   of  Cardiac   Sounds  and  Doubling  of 

Second  Sounds 181 

(d)  Metallic  Quality  of  the  Heart  Sounds, 182 

(e)  "  Muffled  "  Heart  Sounds 182 

4.  SOUNDS  AUDIBLE  OVER  THE  PERIPHERAL  VESSELS.  .        .        .  182 

('0  Arterial  Sounds .182 

(b)  Venous  Sounds, .183 

CHAPTER   IX. 

(AUSCULTATION  OF  THE  HEART,  CONTINUED.) 

CARDIAC   MURMURS. 
I.  TERMINOLOGY 184 

1.  Mode  of  Production 184 

2.  Place  of  Murmurs  in  the  Cardiac  Cycle 186 

3.  Point  of  Maximum  Intensity,        .......  187 

4.  Area  of  Transmission,    .        .        .•  .        .        .        .        .  188 

5.  Intensity,  Quality,  and  Length, .  190 

6.  Relation  to  Heart  Sounds, 193 

7.  Effects  of  Respiration,  Exertion,  and  Position,     ....  193 

8.  Metamorphosis  of  Murmurs, 194 

II.  FUNCTIONAL  MURMURS, 194 

III.  CARDIO-RESPIRATORY  MURMURS, 197 

IV.  VENOUS  MURMURS, 198 

V.  ARTERIAL  MURMURS 198 

CHAPTER    X. 
DISEASES   OF   THE   HEAKT. 

VALVULAR   LESIONS. 

1.  VALVULAR  AND  PARIETAL  DISEASE, 199 

2.  THE  ESTABLISHMENT  AND  FAILURE  OF  COMPENSATION*,      .        .        .  202 

3.  HYPERTROPHY  AND  DILATATION 205 

4.  VALVULAR  DISEASE, 210 

I    Mitral  Regurgitation,      .........  210 

(a)  Pre-compensatory  Stage, 212 

(>>)  Stage  of  Compensation, 213 


XIV  TABLE  OF  CONTENTS. 

PAGE 

(c)  Stage  of  Failing  Compensation 217 

(d)  Differential  Diagnosis, 218 

II.  Mitral  Stenosis, 220 

1.  First  Stage, 222 

2.  Second  Stage, 224 

3.  Third  Stage, 225 

4.  Differential  Diagnosis, 226 

III.  Aortic  Regurgitation 229 

1.  Inspection,       ...........  230 

(a)  Arterial  Jerking, 231 

(b)  Capillary  Pulsation, 232 

2.  Palpation,         .        .        .        /  233 

3.  Percussion 234 

4.  Auscultation, -  .        .        .        .  234 

5.  Summary  and  Differential  Diagnosis, 237 

6.  Prognosis,        . 238 

7.  Complications,         .        .  238 

IV.  Aortic  Stenosis,        .        .^  .    ' 239 

1.  (a)  The  Murmur,     .'  240 

•(b)  The  Pulse,          .     - 242 

(c)  The  Thrill 243 

(d)  Feeble  Aortic  Second  Sound, 244 

2.  Differential  Diagnosis 243 

V.  Tricuspid  Regurgitation, 246 

1.  («)  The  Murmur,     .        . 247 

(b)  Venous  Pulsation 247 

(c)  Cardiac  Dilatation, 248 

(d)  Feeble  Pulmonic  Second  Sound 248 

2.  Differential  Diagnosis 249 

VI.  Tricuspid  Stenosis,          .        .        . ,  .  250 

VII.  Pulmonary  Regurgitatioi 251 

VIII.  Pulmonary  Stenosis, 252 

IX.  Combined  Valvular  Lesions 253 

(a)  Double  Mitral  Disease, 254 

(b)  Aortic  and  Mitral  Regurgitatiou,  .        .        .        .        .        .  255 

(c)  Aortic  Stenosis  and  Regurgitation 256 

CHAPTER   XI. 
PARIETAL  DISEASE  AND   CARDIAC  NEUROSES. 

I.  PARIETAL  DISEASE  OF  THE  HEART, 257 

1.   Acute  Myocarditis,         ........  257 


TABLE  OF  CONTENTS.  XV 

PAGE 

2.  Chronic  Myocarditis, 258 

3.  Fatty  Overgrowth 260 

4.  Fatty  Degeneration 260 

II.  CARDIAC  NEUROSES 261 

1.  Tachycardia,  .        .        . 261 

2.  Bradycardia, .262 

3.  Arrhythmia, 263 

4.  Palpitation, 264 

III.  CONGENITAL  HEART  DISEASE,     .        . 265 


CHAPTER   XII. 

DISEASES  OF  THE  PERICARDIUM. 

I.  PERICARDITIS, 268 

(a)  Dry  or  Fibrinous, 268 

(b)  Pericardial  Effusion .271 

1.  The  Area  of  Dulness 272 

2.  The  Cardiac  Impulse  and  the  Pulse, 274 

3.  Pressure  Signs, 274 

(c)  Adherent  Pericardium, 276 

1.  Retraction  of  Interspaces, 276 

2.  Limitation  of  Respiratory  Movements, 277 

3.  Absence  of  Cardiac  Displacement  with  Change  of  Position,     .  277 

4.  Hypertrophy  and  Dilatation  not  Otherwise  Explained,  .  277 

5.  Capsular  Cirrhosis  of  the  Liver,         .  ....  277 


CHAPTER   XIII. 

THORACIC  ANEURISM. 

1.  Abnormal  Pulsation, 280 

2.  Tumor, 281 

3.  Thrill, 282 

4.  Diastolic  Shock, 282 

5.  Tracheal  Tug, 283 

6.  Pressure  Signs 284 

7.  Percussion  Dulness 284 

8.  Auscultation, 285 

(a)  Murmurs, 285 

(b)  Diastolic  Shock  Sound 286 


XVI  TABLE  OF  CONTENTS. 

PAGE 

9.  Radioscopy, .  287 

10.  Summary 287 

11.  Diagnosis, 288 


CHAPTER   XIV. 

DISEASES    OF   THE   LUNGS   AND    PLEURA. 
BRONCHITIS,    PNEUMONIA,    TUBERCULOSIS. 

1.  TRACHEITIS 292 

2.  BRONCHITIS,      .        . .292 

(a)  Physical  Signs, 293 

(b)  Differential  Diagnosis 294 

3.  CROUPOUS  PNEUMONIA, 296 

(«)  Inspection, , 296 

(b)  Palpation, 297 

(c)  Percussion, 297 

(d)  Auscultation, 298 

(e)  Summary, 301 

(/)  Differential  Diagnosis, 301 

4.  BRONCHO-PNEUMONIA 302 

5.  PULMONARY  TUBERCULOSIS, 304 

(a)  Incipient  Tuberculosis 304 

(b)  Moderately  Advanced  Cases, 308 

(c)  Advanced  Phthisis, 311 

(d)  Anomalous  Forms  of  Pulmonary  Tuberculosis,      ....  315 

CHAPTER   XV. 

v DISEASES  OF  THE  LUNGS,  CONTINUED.) 

1.  EMPHYSEMA, 817 

(a)  Small-Lunged  Emphysema .        .        .  317 

(b)  Large-Luuged  Emphysema 317 

(c)  Emphysema  with  Bronchitis  and  Asthma, 320 

(d)  Interstitial  Emphysema 321 

(e)  Complementary  Emphysema,  . 321 

(/)  Acute  Pulmonary  Tympanites,       .        .        .        .  ,        .  321 

2.  BRONCHIAL  ASTHMA *.  322 


TABLE  OF  CONTENTS.  xvii 

PAGE 

3.  SYPHILIS  OP  THE  LUNG, 323 

4.  BKONCHIECTASIS, 323 

5.  CIRRHOSIS  OP  THE  LUNG, 324 

6.  EXAMINATION  OP  SPUTA, 324 

(a)  Origin, 324 

(6)  Odor  and  Appearances 325 

(e)  Staining 326 

(d)  Microscopic  Examination 327 

(e)  Description  of  Commoner  Organism, 328 

CHAPTER   XVI. 
DISEASES   AFFECTING  THE    PLEURAL   CAVITY. 

I.  Hydrothorax,         . 330 

II.  Pneumothorax, 330 

III.  Pneumoserothorax  and  Pneumopyothorax, 332 

Differential  Diagnosis  of  Pneumothorax  and  Pneumohydrothorax,    .  334 

IV.  Pleurisy, 336 

1.  Dry  Pleurisy 336 

2.  Pleuritic  Effusion, 338 

(a)  Percussion, 339 

(V)  Auscultation, 345 

(e)  Inspection  and  Palpation, 347 

3.  Pleural  Thickening, 350 

4.  Encapsulated  Pleural  Effusions 350 

5.  Pulsating  Pleurisy  and  Empyema  Necessiutis 350 

6.  Differential  Diagnosis  of  Pleural  Effusions, 354 

V.  Cyto-Diaguosis  of  Pleural  and  Other  Fluids, 354 

(a)  Technique 354 

(b)  Interpretation  of  Results 356 

CHAPTER   XVIL 

ABSCESS,    GANGRENE,    AND   CANCER    OF   THE   LUNG,    PULMO- 
NARY  ATELECTASIS,    (EDEMA   AND   HYPOSTATIC 
CONGESTION, 

1.  Abscess  and  Gangrene  of  the  Lung, 359 

2.  Cancer  of  the  Lung, 360 

3.  Atelectasis, 361 

4.  QSdema  and  Hypostatic  Congestion 362 


xvill  TABLE  OF  CONTENTS. 


CHAPTER   XVIII. 

THE   ABDOMEN   IN    GENERAL,    THE   BELLY   WALLS,    PERITO- 
NEUM,   OMENTUM,    AND   MESENTERY. 

PAGE 

EXAMINATION  OP  THE  ABDOMEN  IN  GENERAL,         ..-•...  354 

1.  The  Omentum,  Mesentery,  and  Peritoneum, 364 

2.  Technique,  I 364 

3.  Inspection, 365 

4.  Palpation, .        .        .        .        .  366 

5.  What  can  be  felt  Beneath  the  Normal  Abdominal  Walls,         .        .  36? 

6.  Palpable  Lesions  of  the  Belly  Walls, 369 

7.  Abdominal  Tumors, 379 

8.  Percussion, 371 

DISEASES  OF  THE  PERITONEUM, 372 

1.  Peritonitis,  Local  or  General,    . 373 

2.  Ascites, 374 

3.  Cancer  and  Tuberculosis, 374 

THE  MESENTERY, .        .        .  375 

1.  Glands,       .        .        .        .        ...        ...        .        .        .375 

2.  Thrombosis, '       .        .        .        .  375 

CHAPTER   XIX. 

THE   STOMACH,    LIVER,    AND    PANCREAS. 

THE  STOMACH 375 

1.  Inspection  and  Palpation,          .        .        .        .        .  .        .  376 

2.  Estimation  of  the  Size,  Position,  Secretory  and  Motor  Power,        .  373 

3.  Examination  of  Contents, 3§1 

(a)  Qualitative  Tests,      . 3^3 

(b)  Quantitative  Estimation  of  Free  HC1  and  of  Total  Acidity,    .  333 

4.  Incidence  and  Diagnosis  of  Gastric  Diseases,    .  .        .        .  334 

THE  LIVER, 386 

(a)  Pain, 387 

(b)  Enlargement 388 

(c)  Atrophy, 391 

(d)  Portal  Obstruction,  . 391 

(e)  Jaundice,  .         .        .     ^ 392 

(/)  Loss  of  Flesh  and  Strength 394 

(g)  The  Infection  Group  of  Symptoms, 394 

(h)  Cerebral  Symptoms  of  Liver  Disease 395 


TABLE  OF  CONTENTS.  XIX 

PAGE 

THE  GALL  BLADDER  AND  BILE,  DUCTS,     .' 395 

1.  Differential  Diagnosis  of  Biliary  Colic,     ......  395 

2.  Enlarged  Gall  Bladder, 396 

3.  Cholecystitis 396 

4.  Results  of  Cholecystitis, .397 

THE  PANCREAS 397 

1.  Cancer, 397 

2.  Acute  Pancreatic  Disease          .  398 

3.  Cyst 398 

4.  Bronzed  Diabetes, 398 


CHAPTER   XX. 
THE   INTESTINES,    SPLEEN,    AND   KIDNEY. 

THE  INTESTINES, 399 

1.  Data  for  Diagnosis 399 

2.  Appendicitis, 401 

3.  Obstruction, 403 

4.  Cancer 404 

5.  Examination  of  Contents, 404 

6.  Parasites, 406 

THE  SPLEEN, .  412 

1.  Palpation, 412 

2.  Percussion, 414 

3.  Causes  of  Enlargement,     . 414 

4.  Differential  Diagnosis  of  the  Various  Causes  of  Enlargement,        •.  415 

THE  KIDNEY .  416 

1.  Incidence  and  Data, 416 

2.  Characteristics  Common  to  Most  Tumors  of  the  Kidney,        .        .  417 

3.  Malignant  Disease 417 

4.  Hydronephrosis  and  Cystic  Kidney, 417 

5.  PerinephVitic  Abscess 418 

6.  Abscess  of  the  Kidney 418 

7.  Floating  Kidney, 419 

8.  Renal  Colic  and  Other  Renal  Pain,   .        ." 419 

9.  Examination  of  the  Urine 420 

(a)  Amount  and  Weight, 421 

(/>)  Optical  Properties, .        .        .422 

(c)  Significance  of  Sediments  (Gross) 423 

10.  Pyuria .        .423 


XX  TABLE  OF  CONTENTS. 

PACK 

11.  Haematuria, 424 

12.  Chemical  Examination  of  the  Urine 425 

(a)  Reaction  of  Normal  Urine. 425 

(b)  Tests  for  Albuminuria, .        .  426 

13.  Significance  of  Albuminuria, 427 

14.  Glucosuria  and  Its  Significance, 428 

15.  The  Acetone  Bodies,          .  430 

16.  Other  Constituents 430 

17.  Microscopic  Examination  of  Urinary  Sediments,      ....  431 

18.  Summary  of  the  Urinary  Pictures  Most  Useful  in  Diagnosis,          .  436 

CHAPTER   XXI. 
THE   BLADDER,    RECTUM,   AND  GENITAL   ORGANS. 

THE  BLADDER 439 

1.  Incidence  and  Data, 439 

2.  Distention, 439 

3.  The  Urine  as  Evidence  of  Bladder  Disease, 441 

THE  RECTUM,        .        .        .     , 442 

1.  Symptoms  which  should  Suggest  an  Examination, ....  442 

2.  Methods,     .        ... 443 

3.  Results, 443 

THE  MALE  GENITALS, 444 

1.  The  Penis, 445 

2.  The  Testes  and  Scrotum 446 

THE  FEMALE  GENITALS,     ........        0        .  447 

1.  Methods, 447 

2.  The  External  Genitals,      .        .        . 448 

3.  The  Uterus,         .        .        . 449 

4.  The  Fallopian  Tubes 450 

5.  The  Ovaries 451 

CHAPTER  XXII. 

THE   LEGS   AND  FEET. 

THE  LEGS - 454 

I.  Hip,         ,        .        . 454 

II.  Groin,      . 454 

III.  Thigh 455 

IV.  Knee,  .    460 


TABLE  OF  CONTENTS.  XXI 

PAGE 

V.  (a)  Lower  Leg 460 

(b)  The  Feet, 462 

(c)  The  Toes, 465 


CHAPTER   XXIII. 
THE  BLOOD. 

EXAMINATION    OF    THE    BLOOD, 4gg 

1.  Haemoglobin, 45(5 

2.  Study  of  the  Stained  Blood  Film, 469 

3.  Counting  the  White  Corpuscles, 475 

4.  Counting  the  Red  Corpuscles 476 

5.  Interpretation  of  These  Diita,    . 477 

(a)  Secondary  Anaemia, 477 

(b)  Chlorosis 478 

(c)  Pernicious  Amtmia, 473 

(d)  Leucocytosis, 480 

(e)  Lymphocytosis, 481 

(/)  Eosinophilia, 48i 

(g)  Leuk;emia, 482 

6.  The  Widal  Reaction, 483 

7.  Blood  Parasites, 484 

(«)  Malaria, 484 

(b)  Trypanosoma, 485 

(c)  Filaria 485 

8.  Estimation  of  Coagulation  Time, 487 


CHAPTER  XXIV. 

THE  JOINTS. 

EXAMINATION  OF  THE  JOINTS, 488 

1.  Methods  and  Data, 488 

2.  Technique, 489 

JOINT  DISEASES, 493 

1.  Infectious  Arthritis, 494 

2.  Atrophic  Arthritis, 498 

3.  Hypertrophic  Arthritis, 500 

4.  Gouty  Arthritis, 503 

5.  Htumophilic  Arthritis 505 

6.  Relative  Frequency  of  the  Various  Joint  Lesions,    ^        .        .        .  506 


xxil  TABLE  OF  CONTENTS. 

CHAPTER,   XXV. 
THE   NERVOUS   SYSTEM. 

PACK 

EXAMINATION  OF  THE  NERVOUS  SYSTEM,  .        .        .        .        .        .        .  507 

I.  Disorders  of  Motion, 507 

II.  Disorders  of  Sensation, 511 

III.  Reflexes,         .  512 

IV.  Electrical  Reactions, 517 

V.  Speech  and  Handwriting, 518 

VI.  Trophic  Vasomotor  Disorders,      .        .        .        .        .        .        .  519 

VII.  The  Examination  of  Psychic  Functions ;  Coma,          .        .        .  519 

APPENDICES. 

APPENDIX  A. — DISEASES  OF  THE  MEDIASTINUM 523 

1.  Mediastinal  Tumors, 533 

2.  Mediastinitis 526 

3.  Tuberculosis  of  Mediastinal  Glands,         .     -   .        .        .        .        .  526 

APPENDIX  B. — ACUTE  ENDOCARDITIS 527 

APPENDIX  C. — EXAMINATION  OF  INFANTS'  CHESTS, 528 

APPENDIX  D. — RADIOSCOPY  OF  THE  CHEST,      ......  529 

APPENDIX  E. — THE  SPHYGMOGRAPH, 536 

APPENDIX  F.—  THE  PARAVERTEBRAL,  TRIANGULAR  AREA  OF   DULNESS 

IN  PLEURAL  EFFUSION,      .  .  ....  537 


PHYSICAL  DIAGNOSIS. 


CHAPTER   I. 

DATA    RELATING    TO    THE    BODY    AS    A 
WHOLE. 

I.   WEIGHT. 

To  weigh  the  patient  should  be  part  of  every  physical  examina- 
tion, and  every  physician's  office  should  contain  a  good  set  of 
scales. 

1.  Gain  in  tveight,  aside  from  seasonal  changes,  the  increase  in 
normal  growth,  and  convalescence  from  wasting  diseases,  means 
usually : 

(a)  Obesity. 

(6)  The  accumulation  of  serous  fluid  in  the  body — dropsy,  evi- 
dent or  latent. 

The  first  of  these  needs  no  comment.  Latent  accumulation  of 
fluid,  not  evident  in  the  subcutaneous  tissues  or  serous  spaces,  oc- 
curs in  some  forms  of  uncompensated  cardiac  or  renal  disease,  and 
gives  rise  to  an  increase  in  weight  which  may  delude  the  physician 
with  the  false  hope  of  an  improvement  in  the  patient's  condition, 
but  in  reality  calls  for  derivative  treatment  (diuresis,  sweating). 

Obvious  dropsy  has,  of  course,  the  same  effect  on  the  weight 
and  the  same  significance. 

(c)  Myxoadema  is  occasionally  a  cause  of  increased  weight,  i.e., 
when  the  myxoedematous  infiltration  is  widespread  (see  below,  page 
10). 


2  PHYSICAL  DIAGNOSIS. 

2.  Loss  of  Weight. — The  aging  process  is  so  often  associated 
with  loss  of  weight  that  some  writers  speak  of  the  "  cachexia  of  old 
age."  In  sonae,  a  rapid  loss  of  superfluous  fat  may  occur  at  moder- 
ate age,  e.g.,  at  fifty-five,  and  may  give  rise  to  grave  apprehension 
though  the  general  health  remains  good  and  no  known  disease  de- 
velops. 

Aside  from  this  physiological  change  of  later  life,  most  cases  of 
loss  of  weight  are  due  to : 

(a)  Malnutrition. 

(#)  Loss  of  sleep  .(whether  from  pain  or  other  cause). 

(c)  Infectious  fevers  and  other  toxaemic  states. 

Under  the  head  of  malnutrition  come  the  cases  of  cesophageal 
stricture,  chronic  dyspepsia  (with  or  without  gastric  ulcer  or  dila- 
tation) and  gastric  cancer,  chronic  diarrhoea,  the  atrophies  of  in- 
fancy, diabetes  rnellitus,  and  the  rare  cases  of  anorexia  nervosa. 

Loss  of  sleep  is,  I  believe,  the  chief  factor  in  the  emaciation  oc- 
curring in  many  painful  illnesses  as  well  as  in  various  other  types 
of  disease.  It  is  only  in  this  way  that  I  can  account  for  the  marked 
emaciation  in  many  cases  of  thoracic  aneurism. 

Toxcemia  is,  I  suppose,  accountable  for  part  at  least  of  the  ema- 
ciation in  typhoid,  cirrhotic  liver,  and  tuberculosis. 

II.  TEMPERATURE. 

The  method  of  taking  temperature  is  too  familiar  to  need  expla- 
nation, but  the  student  should  be  aware  of  the  fact  that  hysterics 
and  malingerers  can  and  often  do  raise  the  mercury  in  the  bulb  by 
various  manoeuvres,  unless  they  are  vigilantly  watched.  Dipping 
the  bulb  into  hot  water,  shaking  the  mercury  upward  toward  the 
higher  degrees  of  the  scale,  and  possibly  friction  with  the  tongue 
(?)  are  to  be  suspected. 

In  comatose  patients  and  in  infancy  the  temperature  is  best 
taken  by  rectum.  In  others  we  must  be  sure  that  t]ie  lips  do  not 
remain  open  during  the  test,  so  as  to  reduce  the  temperature  of  the 
mouth. 

1.  fever,  i.e.,  a  temperature  above  99.5^  F.,  in  adults  has  much 


TEMPERATURE.  6 

more  diagnostic  value  than  in  infancy  and  childhood.  In  the  lat- 
ter it  is  often  impossible  to  make  out  any  pathological  condition  to 
account  for  a  fever.  After  childhood  the  vast  majority  of  fevers 
are  found  to  be  due  to : 

(a)  Infectious  disease  or  inflammation  of  any  type. 

(&)  Toxaemia  without  infection — a  much  less  common  and  less 
satisfactory  explanation. 

(c)  Disturbance  of  heat  regulation — as  in  sunstroke,  after  the 
use  of  atropine,  and  in  nervous  excitement,  e.y.,  just  after  entering 
a  hospital.1 

For  such  causes  we  search  when  the  thermometer  indicates 
fever. 

Types  of  fever  often  referred  to  are : 

(a)  "  Continued  fever,"  one  which  does  not  return  to  normal  at 
any  period  in  the  twenty-four  hours,  as  in  many  cases  of  typhoid, 
pneumonia,  and  tuberculosis. 

(&)  "Intermittent"  "hectic,"  or  "septic"  fever,  one  which  disap- 
pears once  or  more  in  twenty-four  hours,  as  in  double  tertian  mala- 
ria and  septic  fevers  of  various  types  (including  mixed  infections  in 
tuberculosis). 

A  fever  which  disappears  suddenly  and  permanently  is  said  to 
end  by  "crisis,"  while  one  which  gradually  pisses  off  in  the  course 
of  several  days  ends  by  "lysis." 

Long-continued  fevers — i.e.,  those  lasting  two  weeks  or  more — 
are  usually  due  (in  the  temperate  zone)  to  one  of  three  causes: — 
Typhoid,  tuberculosis,  sepsis. 

In  1,000  "long  fevers"  (as  above  defined)  the  following  causes 
were  found  in  the  medical  records  of  the  Massachusetts  General 
Hospital : 

Typhoid  Fever 586  \ 

Tuberculosis 192  [  926,  or  92.6  per  cent. 

Pyogenic  Infections 148  ) 

1  The  latter  event  may  also  reduce  (temporarily)  a  high  fever  to  normal  or 
below  it.  In  coma  from  any  cause  (uraemia,  cerebral  hemorrhage,  diabetic 
coma)  fever  often  occurs. 


4  PHYSICAL  DIAGNOSIS. 

Epidemic  Meningitis 27 

"Influenza" 10 

Infectious  Arthritis 9 

("rheumatism") 

T   x  K  Y  74,  or  7.4  per  cent. 

Leucaemia 5 

Cancer 4 

Syphilis 2 

Miscellaneous 17 

2.  Subnormal  temperature  is  often  seen  in  wasting  disease  (can- 
-cer),  nephritis,  uncompensated  heart  disease,  and  myxoedema.     It 

is  rarely  of  diagnostic  value,  but  is  a  rough  measure  of  the  degree 
of  prostration. 

3.  Chills  (due  usually  to  a  sudden  rise  in  temperature)  are  seen 
chiefly  in:    («)  Sepsis    of   any  type;     (£)  Malaria;    (c)  Onset  of 
acute  infections;   (d)  "Nervous "  states. 

After  the  passage  of  a  catheter,  after  or  during  labor,  and  after 
infusion  of  saline  solution,  a  chill  is  often  seen,  but  not  easily  ex- 
plained. 

True  chill,  with  shivering  and  chattering  teeth,  is  distinguished 
from  chilliness  without  any  shivering.  Chilliness  is  far  less  signifi- 
cant and  often  goes  without  fever;  true  chill  rarely  does. 

The  cause  of  true  chills  can  usually  be  determined  by  blood 
examination  (leucocytosis,  malarial  parasites)  and  by  the  general 
physical  examination. 

4.  Night  Sweats  and  Day  Sweats. 

Sweating  in  disease  seems  to  be  conditioned  by :  (a)  Fever  (in- 
fection); (b)  Weakness;  (c)  Sleep. 

A  phthisical  patient  who  falls  asleep  in  the  daytime  will  sweat 
then  and  there,  and  the  sweating  will  stop  when  he  Avakes.  In  ty- 
phoid fever  and  pneumonia  sweating  often  begins  in  convalescence 
when  the  temperature  is  nearly  or  quite  normal.  In  alcoholism, 
hyperthyroidism,  and  neurasthenic  states  we  sometimes  see  sweating 
without  fever. 

Sepsis,  acute  rheumatism,  and  tuberculosis  are  the  infections 
most  often  accompanied  by  sweating.  In  rickets  the  head  sweats 
especially. 


CHAPTER   II. 

THE    HEAD    AND    FACE;     THE    NECK. 

THE   HEAD    AND   FACE. 

ALMOST  all  that  we  can  learn  about  the  manifestations  of  dis- 
ease on  the  head  and  face  is  to  be  learned  by  the  use  of  our  eyes, 

by  inspection,  as  the  term  is.  Other 
methods — percussion,  cc-ray,  palpa- 
tion— yield  but  little.  I  shall  begin 
at  the  top. 

I.  THE  CRANIAL  VAULT. 

1.    The  Shape  and.  Size  of  the 
Cranium. 

The  shape  and  size  of  the  cranium 
concern  us,  especially  in  children. 

(a)  Abnormally  small  crania  (mi- 
crocephalia)  are  apt  to  mean  idiocy, 
especially  if  the  sutures  are  closed. 

(i)  An   abnormally  large  head  is 
seen  in  hydrocephalus  (see  Fig.   1), 
associated    with   enormous    "  open " 
FIG.  i.— Hydrocephalus.  areas  uncovered  by  bone  and  a  pe- 

culiar downward  inclination  of  the 

eyes,  which  are  partly  covered  by  the  eyelids  and  show  a  white 
margin  above  the  iris.     This  condition  is  to  be  distinguished  from  the 


PHYSICAL  DIAGNOSIS. 


(c)  Rachitic  head,  which  is  flatter  at  the  vertex  and  more  pro- 
tuberant at  the  frontal  eminences,  giving  it  a  squarish  outline,  con- 
trasted with  the  globular  shape  and  rounded  vertex  of  the  hydro' 
cephalic.     In  rickets  there  are  no  changes  in  the  eyes. 

(d)  In  adult  life  an  enlargement  of  the  skull,  due  to  bony  thick- 


FIG.  2.— Paget's  Disease.    (Edes.)    a.  Before  onset  of  byperostosis  cranii.    b,  After  onset  of  by- 

perostosis  cranii. 

ening,  forms  part  of  the  rare  disease,  osteitis  deformans  (Paget's 
disease),  associated  with  thickening  and  bowing  of  the  long  bones 
(see  Fig.  2). 

2.    The  Fontanels. 

The  anterior  and  larger  fontanel  remains  about  the  same  size  for 
the  first  year  of  life,  then  diminishes,  and  closes  about  the  twenti- 
eth month.  The  posterior  closes  in  about  six  weeks.  In  rickets, 
hydrocephalus,  hereditary  syphilis,  and  cretinism,  the  fontanels 
and  sutures  remain  open  after  the  normal  time  limit. 

(a)  Bulging  fontanels  mean  increased  intracranial  tension  (hy- 
drocephalus, hemorrhage,  meningitis,  or  any  acute  febrile  disease 
without  dyspnoea),  (b)  Depressed  fontanels  are  seen  in  severe  diar- 


THE  HEAD  AND  FACE.  ~ 

rhoea,  wasting  diseases,  collapsed  states,  and  acute  dyspnoeic  condi- 
tions. 

3.    The  Hair. 

(«)  A  rachitic  child  often  rubs  the  hair  off  the  back  of  its  head 
by  constant  rolling  on  the  pillow.     (This  is  associated  with  profuse 


FIG.  3. — Syphilis  of  the  Frontal  Bone.    (Curschmann.) 

sweating  of  the  head.)  Patchy  baldness  occurs  in  the  skin  disease 
alopecia  areata,  and  occasionally  over  the  painful  area  in  trigem- 
inal  neuralgia. 

(&)  General  loss  of  hair  occurs  normally  after  many  acute  fevers 
and  with  advancing  age.  Early  baldness  (under  thirty-five)  is  often 
hereditary.  Si/philta  may  produce  a  rapid  loss  of  hair,  local  or 


8 


PHYSICAL  DIAGNOSIS. 


general,  and  the  same  is  true  of  myxcedema;  but  in  both  these  dis- 
eases the  hair  usually  grows  again  in  convalescence. 

(c)  Parasites  (pedlculi)   are  worth  looking  for  in  the   dirtier 
classes  and  those  associated  with  them  (teachers).     Their  eggs  ad- 


FIG.  4.— Acromegalia. 


An  eczema 


here  to  the  hairs  and  are  familiarly  known  as  "nits." 
or  itching  dermatitis  often  results. 

II.  THE  FOKEHEAD. 

Scars,  eruptions,  and  bony  nodes  are  important, 
(a)  Scars  may  be  due  to  trauma  or  to  old  syphilitic  periostitis. 
The  epileptic  often  cuts  his  forehead  in  falling. 


THE  HEAD  AND  FACE. 


9 


(&)  Eruptions  often  seen  cm  the  forehead  are  those  of  acne, 
syphilis,  and  smallpox.  These  may  resemble  each  other  closely, 
and  are  to  be  distinguished  by  the  history,  the  presence  of  lesions 


FIG.  5.— Typical  Face  in  Acromegaly. 

on  other  parts  of  the  body,  and  the  concomitant  signs  (fever,  pros- 
tration, etc.). 

(c)  Nodes  may  be  the  result  of  many  bumps  in  childhood  or  may 
be  caused  by  a  syphilitic  periostitis  (see  Fig.  3).  The  history  must 
decide. 

III.   THE  FACE  AS  A  WHOLE. 

Very  characteristic  even  at  a  glance  is  the  face  of  (a)  acrome- 
galia.  A  strong  family  likeness  seems  to  pervade  all  well-marked 


10 


PHYSICAL  DIAGNOSIS. 


cases  (see  Figs.  4  and  5).  The  huge,  bony  "whopper  jaw"  is  the 
most  striking  item,  then  the  prominent  cheek  bones,  and  the  ridge 
above  the  eyes.  The  nose  and  chin  are  very  large. 

(&)  Myxoedema  (see  Fig.  6)  is  not  so  characteristic  and  might 
easily  be  mistaken  for  nephritis  or  normal  stupidity  with  obesity. 
The    presence    of    dry   skin,    falling 
hair,  mental  dulness,  and  subnormal 
temperature,   all   supervening   simul- 
taneously   within    a    few    weeks    or 


FIG.  6.— Myxuedema. 


FIG.  7.— Cretinism. 


months,  make  us  suspect  the  disease.  Palpation  sho\\s  that  the 
puffiness  of  the  face  is  not  true  oedema,  as  it  does  not  pit  on  press- 
ure. 

(c')  Cretinism — the  infantile  form  of  myxoedema — can  generally 
be  recognized  by  sight  alone  (see  Fig.  7).  Here  the  tongue  is 
often  protruded,  and  there  are  often  pot-belly  and  deformed  legs. 

(d~)  In  adenoids  of  the  nasopharynx  the  child's  mouth  is  often 
open,  the  nose  looks  pinched,  the  expression  is  stupid  (see  Fig.  8). 


THE  HEAD  AND  FACE. 


11 


There  is  a  history  of  mouth-breathing  and  snoring,  with  frequent 
"colds,"  a  high-arched  palate,  and  perhaps  deafness. 

(e)  In  paralysis-  agitans  the  "mask-like"  face  shows  almost  no 
change  of  expression,  whatever  the  patient  says  or  does.  The  neck 
is  usually  inclined  forward,  and  so  rigid  that  when  the  patient 


FIG.  8.— Adenoid  Face.    (Schadle.) 


wishes  to  look  to  right  or  left  his  whole  body  rotates  like  a  statue 
on  a  pivot. 

(/)  In  Graves'  disease  (exophthalmic  goitre)  the  startled  jor 
frightened  look  is  characteristic,  though  the  expression  is  almost 
wholly  due  to  the  bulging  of  the  eyes  and  their  quick  motions 
(Fig.  9). 

(<7)  In  leprosy  the  general  expression  is  of  a  superabundance  of 
skin  on  the  patient's  face,  reminding  us  of  some  animal  ("leonine 
face")  (Fig.  10). 

(7i)  In  early  jihthisis  one  often  notices  the  clear,  delicate  skin, 


12 


PHYSICAL  DIAGNOSIS. 


fine  hair,  long  eyelashes,  wide  pupils — "appealing  eyes."     Pallor 
and  a  febrile  flush  (hectic)  come  later  in  some  cases. 

(?!)  After  vomiting  the  face  has  often  a  drawn,  pinched,  anxious 
look,  which  has  often  been  supposed  to  be  characteristic  of  general 
peritonitis,  intestinal  obstruction,  or  other  diseases  accompanied  by 

vomiting;  but  I  do  not  recognize 
any  single  expression  as  charac- 
teristic of  peritoneal  lesions. 
(_/)   Chronic  alcoholism  may 


1 


FIG.  9.— Exophthalmic  Goitre.    (Meltzer.) 


FIG.  10.— Face  in  Leprosy. 


be  shown  not  only  in  a  red  nose,  but  oftener  in  a  peculiar,  smoothed- 
oid  look,  due,  I  suppose,  to  an  extra  but  evenly  distributed  ac- 
cumulation of  subcutaneous  fat. 

(&)  An  cedematous  or  swollen  face  is  much  more  easily  noticed 
by  the  patient  or  his  friends  than  by  one  who  is  not  familiar  with 
his  normal  look.  It  usually  points  to  nephritis,  but  may  occur  in 
heart  disease,  and  sometimes  (especially  in  the  morning)  without 
any  known  cause.  When  combined  with  anaemia,  the  puffy  face 
gives  a  peculiar  "  pasty  "  look  (chronic  diffuse  nephritis). 


THE  HEAD  AND  FACE.  13 

IV.  MOVEMENTS  OF  THE  HEAD  AND  FACE. 

1.  The  Shaking  Head. 

This  occurs  often  in  old  age,  occasionally  in  paralysis  ayitans 
(which  oftener  affects  the  hands),  and  in  toxic  conditions  (alcohol, 
tobacco,  opium).  In  some  cases  no  cause  can  be  found. 

2.  Sftasms  of  the  Face. 

Spasms  of  the  face,  i.e.,  sudden,  quick  contractions  of  certain 
facial  muscles,  such  as  winking-spasm,  jerking  of  a  corner  of  the 
mouth,  or  sniffing,  occur  chiefly: 

(ft)  As  a  matter  of  habit  without  other  disease. 

(6)  As  a  part  of  the  disease  chorea,  associated  with  similar 
"  restless "  motions  of  the  hands  and  feet.  We  often  see  these 
spasms  in  school-children ;  occasionally  in  pregnant  women. 

(c)  By  imitation,  in  schools  and  institutions,  these  spasms  may 
spread  like  an  epidemic. 

From  habit  spasms,  which  persist  for  months  or  years  in  one  or 
two  groups  of  muscles,  true  chorea  is  distinguished  by  its  involve- 
ment of  the  hands,  feet,  and  other  parts,  by  its  frequent  association 
with  joint  pain  and  endocarditis  (see  page  493),  and  by  its  short 
course  (eight  to  ten  weeks  on  the  average). 

In  hysterical  conditions  and  hereditary  brain  defects,  various 
other  spasms  occur  (see  below,  page  506). 

V.  THE  EYES. 

I  shall  not  attempt  to  deal  with  lesions  essentially  local  (such 
as  a  "  sty  " ) ,  and  shall  confine  myself  to  data  that  have  diagnostic 
value  iu  relation  to  the  rest  of  the  body. 

1.    (Edema  of  the  Lids. 

(Edema  of  lids,  especially  the  lower,  often  accumulates  in  the 
night  and  is  seen  in  the  early  morning,  without  known  cause  or 


14  PHYSICAL  DIAGNOSIS. 

after  a  debauch.  In  other  cases  it  usually  points  to  the  existence 
of: 

(a)  Nephritis  (prove  by  urinary  examination). 

(i)  Anaemia  (prove  by  blood  examination). 

(c)  Measles  and  whooping-cough  (eruption,  paroxysms  of  cough). 

Rarer  causes  are  trichiniasis,  angioneurotic  oedema,  and  erysipelas. 

Trichiniasis  is  recognized  by  the  presence  of  fever,  muscular  ten- 
derness, and  an  excess  of  eosinophiles  in  the  blood. 

In  angioneurotic  oedema  there  is  usually  a  previous  history  of 
similar  transitory  swellings  in  other  parts  of  the  body. 

The  acute  onset,  red  blush,  high  fever,  and  general  prostration 
distinguish  the  oedema  of  erysipelas. 

2.   Dark  Circles  under  the  Eyes 

may  appear  in  any  debilitated  stage,  e.g.,  from  loss  of  sleep,  hun- 
ger, menstruation,  masturbation,  etc. 

3.    Conjunctivitis. 

This  affection  forms  part  of  hay  fever,  measles,  yellow  fever, 
and  some  cases  of  influenza.  It  may  also  occur  as  an  independent 
infection.  It  follows  overdoses  of  iodide  of  potash  or  arsenic. 
The  whole  conjunctiva  is  reddened,  in  contradistinction  from  the 
reddening  about  the  iris  seen  in  iritis. 

4.  Jaundice. 

Jaundice,  the  yellow  coloration  of  the  white  of  the  eye  by  bile 
pigment,  is  easily  recognized  and  can  be  confounded  only  with  sub- 
con  junctival  fat,  which  differs  from  jaundice  in  that  it  appears  in 
spots  and  patches,  not  covering  the  whole  solera,  as  jaundice  does. 

The  skin,  mucous  membranes,  urine,  and  sweat  are  also  bile- 
stained  in  most  cases,  and  the  circulation  of  the  bile  in  the  blood 
often  produces  slow  pulse,  itching,  and  mental  depression.  Lack  of 
bile  in  the  gut  leads  to  flatulence  and  clay-colored  stools. 

The  commonest  causes  are:    (a)    Biliary  obstruction  (catarrh, 


THE  HEAD  AND  FACE.  15 

stone  or  tumors  obstructing  the  bile   ducts,   hepatic  cirrhosis,  or 
syphilis  constricting  them). 

(7>)  Toxaemia  (malaria,  sepsis,  icterus  of  the  new-born,  perni- 
cious anaemia). 

5.    The  Pupils, 

The  normal  reflexes  to  light  and  distance  are  tested  as  follows : 
Let  the  patient  face  the  light  and  cover  one  eye  with  the  hand. 
On  withdrawing  the  hand,  the  pupil  contracts.  Then  turn  the  pa- 
tient away  from  the  light  and  let  him  look  at  the  farthest  corner  of 
the  room.  The  pupil  expands.  Make  him  look  at  your  ringer  a 
few  inches  distant  from  his  eyes.  The  pupil  contracts.  Each  pu- 
pil should  bo  examined  separately. 

The  value  of  the  pupils  in  diagnosis  lias  been  greatly  overesti- 
mated. There  are,  in  fact,  comparatively  few  conditions  in  which 
they  yield  us  important  diagnostic  evidence,  for,  although  they  are 
very  often  abnormal,  the  abnormalities  are  seldom  characteristic  of 
any  single  pathological  condition  and  throw  little  light  on  the  diag- 
nosis. 

A.  The  ARGYLL-KOBERTSON  PUPIL  reacts  to  distance,  but  not  to 
light.     It  is  of  great  value  as  a  factor  in  the  diagnosis  of  tabes  dor- 
sahs  and  dementia  paralytica. 

B.  DILATED  PUPILS.— (a)  Many  phthisical    patients    show  a 
more  or  less  transient  dilatation  of  one  or  both  pupils.      (&)  Blind- 
ness or  deficient  sight  (from  any  cause)  may  cause  dilatation  of  the 
pupil,     (c)  Other  common  causes  are  distress  or  strong  emotion  from 
any  cause,  many  fevers  and  comatose  states,  and  the  use  of  mydri- 
atic  drugs. 

C.  CONTRACTED  PUPILS  are  common  in  old  age  and  in  photo- 
phobia from  any  cause.     Disease  high  up  in  the  spinal  cord  (tabes, 
general  paralysis,  etc.)  may  produce  contraction  (spinal  myosis)  by 
paralyzing  the  sympathetic  dilators.     Aortic  aneurism  may  produce 
in  the  same  way  contraction  of  one  pupil  (see  below,  page  284). 

D.  CONTRACTION  WITH  IRREGULAR  OUTLINE  and  sluggish  reac- 
tions is  often  seen  in  iritis  as  a  result  of  adhesions  to  the  lens  (pos- 
terior synechise). 


16  PHYSICAL  DIAGNOSIS. 

6.    The   Cornea. 

(a)  Arcus  senilis,  a  grayish  ring  at  the  circumference  of  the 
cornea,  is  one  of  the  classical  signs  of  old  age  and  arteriosclerosis. 

(l>)  Syphilitic  keratitis,  usually  seen  in  the  hereditary  form  of 
the  disease,  produces  an  irregularly  distributed  haziness  of  the  cor- 
nea, usually  in  both  eyes  and  before  the  sixteenth  year.  Diagnosis 
depends  on  other  evidences  of  syphilis. 

VI.  OCULAR  MOTIONS. 

(a)  Ptosis,  or  dropping  of  the  eyelid,  is  usually  unilateral  and 
dependent  on  paralysis  of  the  third  nerve.  Its  most  frequent  cause 
is  syphilis.  The  eye  is  usually  drawn  out  by  the  action  of  the  un- 
paralyzed  external  rectus.  Moderate,  bilateral  ptosis  is  common  in 
hysterical  and  neurasthenic  conditions. 

(I))  Squint  (strabismus)  is  called  external  if  the  eye  turns  out, 
internal  if  it  turns  in.  Of  its  many  types  and  causes  I  mention 
only  the  acute  cases  due  to  intracranial  lesions,  such  as  tuberculous 
and  epidemic  meningitis,  syphilis,  tumors. 

(c)  Nystagmus  is  a  rapid  horizontal  oscillation  of  both  eyeballs. 
It  may  be  the  result  of  albinism  or  of  various  local  eye  troubles,  but 
is  an  important  member  of  the  symptom  group  characteristic  of 
multi-pie  sclerosis.  It  may,  however,  occur  in  many  other  brain  le- 
sions. Rarely  the  oscillation  is  vertical. 

VII.  THE  RETINA. 

The  lesions  which  are  of  greatest  interest  in  general  medicine 
are :  Retinal  hemorrhage,  optic  neuritis,  and  optic  atrophy. 

(a)  Retinal  hemorrhages,  with  or  without  other  retinal  changes, 
are  important  signs  of  nephritis,  grave  anosmias,  and  diabetes. 

(£)  Optic  neuritis  (usually  bilateral)  is  of  great  value  in  the 
diagnosis  of  brain  tumors,  tuberculous  meningitis,  and  brain  abscess. 
It  also  forms  part  of  the  lesions  in  many  cases  of  nephritis  and 
diabetes. 

(c)  Optic  atrophy  may  be  the  end  result  of  any  of  the  types  of 
optic  neuritis  just  mentioned,  or  in  a  primary  form  is  important 


THE  HEAD  AND  FACE.  17 

evidence  of  tabes  dorsalis.     Many  cases  occur  without  any  known 
cause. 

VIII.   THE  NOSE. 

1.  Size  and  Shape.— The  enlargement  of  all  the  tissues  of  the 
nose  occurring   in    acromegaly   has    already    been   mentioned.     In 
myxcedema.  the  nostrils  are  sometimes  thickened  and  the  whole  nose 
loses  its  delicacy  of  shape.     A  red  nose  is  popularly  and  correctly 
associated  with  alcoholism,  but  in  many  cases  identical  appearances 
are  produced  by  acne  rosacea  or  by  lupus  erythematosus,  as  well  as 
by  circulatory  anomalies  without  any  other  disease. 

Falling  in  of  the  bridge  of  the  nose  may  be  due  to  syphilis  of 
the  nasal  bones,  especially  when  there  are  scars  over  the  sunken 
portion,  but  is  sometimes  present  without  any  disease. 

The  small,  narrow  nose  associated  with  adenoid  growths  has 
already  been  mentioned. 

2.  The  nostrils  move  visibly  in  many  conditions  involving  dysp- 
noea (diseases  of  the  heart  and  lungs,  acute  infections,  etc.),  and 
this  is  sometimes  useful  in  suggesting  to  the  physician  the  possibil- 
ity of  pneumonia,  hitherto  unsuspected.     Dried  blood  in  the  nostrils 
may  be  of  value  as  evidences  of  recent  nosebleed. 

3.  Nosebleed  suggests  especially  trauma,  infectious  fevers  (par- 
ticularly typhoid),  and  hemorrhagic  diseases  (purpura,  haemophilia, 
acute  leukaemia). 

4.  A  nasal  discharge  in  a  young  infant  ("  snuffles  ")  suggests 
hereditary  syphilis.     In  adults  the  familiar  "  cold  in  the  head"  may 
need  a  bacteriological   examination  to  exclude   thk  possibility  of 
nasal  diphtheria  or  to  con  firm  a  diagnosis  of  influenza. 

5.  A  small,  indolent,  long-standing  sore  on  the  nose  or  neai^the 
corner  of  the  eye  should  always  suggest  epithelioma  and  tuberculo- 
sis.    Microscopic  examination  may  be  necessary  to  determine  the 
diagnosis. 

6.  The  consideration  of  local  disease  within  the  nose  does  not  fall 
within  the  scope  of  this  book,  but  is  suggested  by  local  pain,  diffi- 
culty in  breathing  through  the  nose,  frequent  "  colds,"  and  asthma. 

(For  the  examination  of  the  ears,  see  below,  p.  505.) 
2 


18  PHYSICAL  DIAGNOSIS 

IX.  THE  LIPS. 

1.  Pallor  of  the  mucous  membrane  of  the  Jips  .suggests,  though 
it  never  proves,  anaemia.     No  diagnosis  of  anaemia  should  be  made 
without  at  least  testing  the  haemoglobin  (Tallqvist's  scale).     One 
minute  suffices. 

2.  Cyanosis,  a  purplish  or  slatey-blue  color  of  the  lips,  occurs 
in  some  healthy  persons  from  simple  "weathering."      When  well 
marked,  however,   it  should  always  suggest: — (a)    Heart  disease 
(especially  mitral  or  congenital  lesions). — (6)  Lung  diseases  (espe- 
cially emphysema  and  pneumonia). — (c)  Poisoning  by  acetanilid  or 
other  coal-tar  antipyretics,  producing  inethsemoglobiiisemia.1 

The  last  is  easily  tested  by  noting  the  brownish  (not  red)  tint 
of  the  blood  when  soaked  into  filter  paper,  as  in  performing  Tall- 
qvist's haemoglobin  test;  the  test  should  be  confirmed  by  the  his- 
tory. Disease  of  the  heart  or  lung  is  identified  by  physical  exami- 
nation of  the  chest. 

3.  Parted  lips,  an  open  mouth,  may  be  a  mere  habit  or  may  be 
due  to  nasal  obstruction  (adenoids).      Idiots  and  cretins  are  very 
apt  to  keep  their  mouths  open,  whether  there  is  enlargement  of  the 
tongue  or  not.     Dyspnoea  may  compel  a  patient  to  keep  his  mouth 
open  so  as  to  get  more  air. 

In  cold  weather  a  crack  ov  fissure  may  appear,  usually  in  the 
centre  of  the  lower  lip,  and  in  poorly  nourished  individuals  may 
persist  for  weeks.  At  the  corners  of  the  mouth  fissures  or  cracks 
maybe  due  to  chapping  or  "cold-sores"  (herpes),  but  if  they  persist 
for  weeks  in  young  children  they  are  very  suggestive  of  syphilis. 
White  linear  scars  radiating  from  the  corners  of  the  mouth  are  pre- 
sumptive evidence  of  healed  syphilitic  lesions,  oftenest  congenital. 

4.  The  mucous  patches   of   syphilis — white,   sharply    bounded 
areas  about  the  size  of  the  little-finger  nail — are  often  seen  at  the 
junction  of  the  skin  with  the  labial  mucous  membrane,  especially  at 
the  corners  of  the  mouth. 

5.  Herpes  ("cold  sores")  is  due  to  a  lesion  of  the  Gasserian 

1  Cyanosis  of  intestinal  origin  occurs  in  connection  with  certain  diseases 
involving  excessive  intestinal  decomposition.  (See  Gibson,  Quarterly  Jour- 
nal of  Medicine,  Oct.,  1907,  p.  29.) 


THE  HEAD  AND  FACE. 


19 


FIG.  11.— Epithelioma  of  the  Lip. 


ganglion,  with  resulting  "  trophic  "  disturbances  of  the  regions  sup- 
plied by  the  trigeminal  nerve.  Appearing  first  as  a  cluster  of  vesi- 
cles ( "  water  blisters  "  )  which  break  and  leave  a  small  sore  near  the 
mouth,  herpes  is  to  be  distinguished  by :  (a)  its  distribution,  near 
the  terminations  of  some  branch  or  branches  of  the  trigeminal  nerve 
("  herpes  f  rontalis,  nasalis, 
labialis");  (&)  by  its  lasting 
but  a  few  days;  and  (c)  by 
the  absence  of  similar  lesions 
elsewhere.  It  may  be  con- 
nected with  a  "cold"  (which 
is  often  a  disease  of  the  tri- 
geminus),  but  it  frequently 
occurs  without  any  discov- 
erable cause.  Herpetic  stomatitis  ("canker  sores")  may  accom- 
pany it. 

6.  Epithelioma 1  of  the  Up  and  chancre  should  be  suspected  when- 
ever a  long-standing  sore  is  discovered  there.  Epithelioma  occurs 
almost  always  on  the  lower  lip  in  a  man  past  middle  life  (see  Fig. 
11).  It  lasts  longer  than  chancre,  is  slower  in  producing  glandular 

enlargement  at  the  angle  of  the  jaw, 
and  is  not  associated  with  other  syph- 
ilitic lesions. 

7.  Chancre  of  the  lip  is  commoner 
in  women  and  may  occur  at  any  age, 
especially    under    forty.       The    sore 
usually   lasts   but  a    few  weeks,  ex- 
cites early  enlargement  of  the  glands, 
and  is  usually  associated  with  other 
manifestations   of  syphilis   (see   Fig. 
12). 

8.  Angioneurotic    cedema    appears 
as  a  sudden,  painless,  apparently  causeless  swelling  of  the  whole 

1  It  does  harm  to  call  this  lesion  "cancer"  because  this  term  is  so  firmly  as- 
sociated in  the  lay  mind  with  metastasis,  recurrence,  and  death  that  unnec- 
essary suffering  may  result  when  the  patient  or  his  family  learns  that  he  has 
"  cancer. " 


FIG.  12.— Chancre  of  the  Lip. 


20 


PHYSICAL  DIAGNOSIS. 


lip  (see  Fig.  13),  which  may  attain  double  its  normal  si/e.      The 
diagnosis  depends  on  the  exclusion  of  all  known  causes  (trauma, 

infection,  insect  bites)  and  on 
the  history  of  similar  swellings 
(on  the  lip  or  elsewhere)  in  the 
past. 

9.  The  enlargement    of  the 
lips  in  myxoedema  and  cretin- 
ism has  been  mentioned  above 
(page  18). 

10.  Hare-lip  is   a    vertical 
slit   (congenital  deficiency)  in 
the  upper  lip  opposite  to  the 
nostril;  it   is   often   connected 
with  an    antero-posterior  cleft 
through  the  hard  palate  ("  cleft 
palate").     The  lesion  maybe 
double,  leaving  a  small  island 
of  tissue  continuous  with  the 
nasal    septum    (intermaxillary 

bone).     Diagnosis  is  made  at  a  glance. 


FIG.  13.— Anfrfoneurotic  (Edema  of  Lower  Lip. 


X.  THE  TEETH. 

The  first  set  of  teeth  is  fairly  constant  in  its  order  and  date  of 
appearance.  In  Fig.  14  the  number  of  the  month  when  each  tooth 
is  most  apt  to  appear  is  marked  on  the  tooth.  The  second  set  (per- 
manent teeth)  arrives  (less  regularly)  between  the  sixth  and  the 
fifteenth  year,  except  the  "  wisdom 
teeth,"  which  appear  about  the  twenty- 
first  year. 

1.  Rickets  or  cretinism  often  de- 
lays dentition  considerably. 

2.  Congenital  syphilis  may  be  as- 
sociated with  deformities  of  the  cen- 
tral incisors  (permanent).      The  most  FIG.  u. -Diagram  showing  the  Month 

,   .     ,  i     ,     ,  •     i»       « v  at  which  Each  Tooth  (of  the  First  Set) 

constant  is  that  shown  in  Fig.  15.  should  Appear. 


THE  HEAD  AND  FACE. 


21 


3.  Teeth-grinding. — Nervous,  delicate,  oversensitive  children 
often  grind  their  teeth  in  their  sleep.  There  is  no  foundation  for 
the  popular  superstition  that  this  act  indicates  "  worms." 


FIG.  15.— Notched  Incisors  in  Congenital  Syphilis. 

XI.   THE  BREATH. 

Foul  breath  is  oftenest  due  to : 

(<z)  Foul  teeth  and  gums  (neglected). 

(7;)  Stomatitis  of  any  variety. 

(c)  Gastric  fermentation  (with  or  without  constipation). 

Rarer  causes  are  algcess  or  gangrene  of  the  lung,  in  which  the 
breath  may  be  intensely  foul;  the  source  of  the  odor  is  made  evi- 
dent by  the  sputa. 

Acetone  breath  has  a  faintly  sweetish  odor,  which  has  been  com- 
pared to  that  of  chloroform,  new-mown  hay,  and  rotting  apples. 
It  occurs  not  only  in  diabetes,  but  in  various  conditions  involving 
starvation  (vomiting,  fevers),  and  especially,  but  not  only,  a  lack 
of  carbohydrates.1 

In  uraemia  a  foul  odor  is  often  noticed,  and  an  ammoniacal 
("urinous")  smell  has  been  mentioned  by  many  writers.  In  ty- 
plioid  and  in  syphilis  some  persons  seem  to  detect  a  characteristic 
odor,  but  the  evidence  is  insufficient.  Alcoholic  breath  is  often  of 


'See  Taylor:  "Studies  on  an  Ash-free  Diet." 
Publication,  July  30th,  1904. 


University  of  California 


22  PHYSICAL  DIAGNOSIS. 

value  in  correcting  the  false  statements  of  its  possessor.  In  coma- 
tose persons  we  must  remember  that  a  drink  may  have  been  taken 
just  before  an  attack  of  apoplexy  or  any  other  cause  for  coma,  so 
that  an  alcoholic  breath  in  comatose  patients  does  not  prove  that 
the  coma  is  due  to  alcohol. 

In  poisoning  by  illuminating  gas  the  gaseous  odor  of  the  breath 
may  be  noticed. 

XII.  THE  TONGUE. 

The  act  of  protruding  the  tongue  may  give  us  valuable  informa- 
tion on  the  condition  of  the  nervous  system. 

(a)  The  hesitating,  tremulous  tongue  of  typhoidal  states  is  very 
characteristic.  Simple  tremor  is  seen  in  alcoholism,  dementia  par- 
alytica,  and  weakness. 

(i)  If  the  tongue  is  protruded  to  one  side,  it  usually  means  facial 
paralysis  as  part  of  a  hemiplegia;  rarely  it  is  due  to  lesions  of  the 
hypoglossal  nerve  or  its  nucleus  (in  bulbar  paralysis  or  tabes). 

(c)  A  coated  tongue  (due  mostly  to  lack  of  saliva)  is  not  often  of 
much  value  in  diagnosis,  and  there  is  no  need  to  distinguish  the 
varieties  and  colors  of  coats;  but  a  few  suggestions  may  be  obtained 
from  it.  Many  persons  who  seem  otherwise  perfectly  healthy  have 
coated  tongues  in  the  early  morning.  This  is  especially  true  in 
mouth-breathers,  in  smokers,  and  in  those  who  keep  late  hours. 

In  those  whose  tongues  are  usually  clean  the  appearance  of  a 
coat  is  associated  often  with  gastric  fermentation,  constipation,  or 
fevers. 

A  clean  tongue  in  a  dyspeptic  suggests  hyperacidity  or  gastric 
ulcer.  This  point  I  have  found  of  more  value  than  any  inference 
from  a  coated  tongue. 

A  dry,  brown-coated,  perhaps  cracked  tongue  goes  with  serious 
exhausted  states  and  wasting  diseases  with  or  without  fever. 

(</)  Cyanosis  and  jaundice  may  be  seen  in  the  tongue,  but  bet- 
ter elsewhere. 

(e)  Indentation  of  the  edges  of  the  tongue  by  the  teeth  occurs 
especially  in  foul,  neglected  mouths,  but  has  no  diagnostic  value. 

(/)  Herpes  ("canker")  often  occurs  on  the  tongue;  it  begins  as 


THE  HEAD  AND  FACE. 


23 


a  group  of  vesicles,  but  these  rupture  so  soon  that  we  usually  see 
first  a  very  small,  grayish  ulcer  with  a  red  areola.  It  heals  in  a 
day  or  two,  i.e.,  more  quickly  than  the  syphilitic  mucous  patch  or 
any  other  lesion  with  which  it  is  likely  to  be  confounded. 

(#)  Cancer,  tuberculosis,  and  syphilis  may  attack  the  tongue  and 
form  deep,  long-standing  ulcerations.  Syphilis  can  usually  be  diag- 
nosed by  the  history,  the  presence  of  other  syphilitic  lesions,  and 
the  therapeutic  test  (see  Fig.  1G).  Cancer  and  tuberculosis  should 


FIG.  16.— Syphilis  of  the  Tongue. 


be  diagnosed  by  microscopic  examination,  though  cancer  is  more 
commonly  found  in  men  (especially  smokers)  past  middle  life  and 
on  the  side  of  the  tongue. 

(A)  "  Siuifil''  K/ri't-s"  are  due  to  irritation  from  a  tooth  or  to 
trauma,  and  heal  readily  if  their  cause  is  removed. 

(/)  Fissures  of  the  tongue  are  usually  due  to  syphilis,  which  is 
recognized  in  other  lesions. 

(,/)  Lt'itkaiilnkia  Inccalis  (lingual  corns)  refers  to  whitish, 
smooth,  hard  patches  of  thickened  epithelium,  usually  on  the  dor- 
sum  of  the  tongue  in  smokers,  running  a  chronic  course  without 
pain  or  ulceration,  but  important  because  epithelioma  has  been 
known  (and  not  very  rarely)  to  develop  in  them. 

(&)   Geographic  tongue  is  a  desquamation  of  the  lingual  epitlic- 


•24 


PHYSICAL  DIAGNOSIS. 


Hum  in  sinuous  or  circulate  areas,  which  spread  and  fuse  at  their 
edges,  while  the  central  portions  heal,  giving  a  look  something  like 
the  mountain,  ranges  in  a  geographical  map.  It  usually  gives  no 
trouble  unless  the  patient's  attention  becomes  concentrated  on  it. 

(Z)  Hypertrophy  of  the  tongue  has  already  been  mentioned  in 
connection  with  myxcedema  and  cretinism.  It  may  occur  independ- 
ently as  a  congenital  affection. 

XII L   THE  GUMS. 

(a)  A  lead  line  should  be  looked  for  in  every  patient  as  a  matter 
of  routine,  as  it  may  not  be  suggested  by  anything  in  the  patient's 
symptoms  or  history,  yet  may  be  the  key  to  the  whole  case. 

The  deposit  of  lead  sulphide  in  (not  on)  the-  gums  is  not  blue, 
but  gray  or  black;  and  is  not  a  line,  but  a  series  of  dots  and  lines 


FIG.  17.— Lead-dots  In  the  Gums. 


arranged  near  the  free  margin  of  the  gums  and  about  one  millimetre 
from  it.  Where  there  are  no  teeth  there  is  no  lead  line.  In  faint 
or  doubtful  cases  a  hand  lens  is  of  great  assistance  and  shows  up 
the  dotted  arrangement  of  the  deposit  very  clearly  (see  Fig.  17).  It 
is  unfortunate  that  the  term  "  blue  line  "  has  become  attached  xo 
these  gray-black  dots. 


THE  HEAD  AND  FACE.  25 

Sorties,  a  collection  of  epithelium,  bacteria,  arid  food  parti- 
cles, accumulates  about  the  roots  of  the  teeth  with  great  rapidity  in 
febrile  cases,  but  has  no  considerable  diagnostic  importance. 

(c)  Sponyy  and  blendiny    yams  occur   as    part    of   the    disease 
"scurry,"  after  overdoses  of  mercury  or  potassic  iodide,  in  various 
debilitated  states,  and  sometimes  without  known  cause.     The  teeth 
are  loosened  and  the  flow  of  saliva  is  usually  profuse.     The  stench 
from  such  cases  is  often  intolerable. 

(d)  Suppuration  about  the  roots  of  the  teeth  (^pyorrhoea  alveo- 
laris)  is  common  in  neglected  mouths,  and  seems  in  some  cases  to 
injure  digestion,  but  in  most  cases  its  effects  appear  to  be  wholly 
local. 

(e)  Gumboil  (alveolar  abscess),  originating  in  a  carious  tooth,  is 
easily  recognized  by  the  familiar  signs  of  abscess  associated  with  a 
diseased  tooth  and  sometimes  with  a  surprising  amount  of  swelling 
of  the  face. 

(/)  "  Epulis  "  is  a  word  applied  to  various  soft  tumors  spring- 
ing from  the  jaw  bone  or  occasionally  from  the  gums  themselves. 
Many  of  them  are  sarcomatous,  but  microscopic  examination  is  nec- 
essary to  distinguish  these  from  fibroma,  granulonia,  and  angionia. 

XIV.   THE  BUCCAL  CAVITY. 
1.    Eruption*. 

(a)  Koplik's  spots  in  measles  are  of  much  importance.  They 
appear  chiefly  in  the  inside  of  the  cheeks,  opposite  the  line  of  clos- 
ure of  the  molars,  and  consist  of  minute,  bluish-white  spots,  each 
surrounded  by  a  red  areola  and  sometimes  fusing  into  larger  red 
areas. 

(6)  The  syphilitic  mucous  patch  (see  above)  should  be  looked 
for  in  suspicious  cases,  not  only  in  easily  accessible  parts  of  the 
mou tli,  but  round  the  roots  of  the  gums,  where  the  cheeks  or  lips 
have  to  be  pushed  away  to  afford  a  good  view. 


26  PHYSICAL  DIAGNOSIS. 

2.   Pigmentations. 

In  Addison's  disease  brown  spots  or  patches  often  occur  on  any 
part  of  the  mucous  membrane  of  the  mouth.  They  may  also  occur 
in  negroes  without  any  disease  and  after  ulcerations  (e.g.,  from  a 
tooth),  so  that  they  are  not  distinctive  of  Addison's  disease. 

3.    Gangrene. 

Gangrene  (stomatitis  gangrenosa,  "noma"),  a  rare  disease  of 
weakly  children,  starts  as  a  hard  red  spot  inside  the  cheek  and 
usually  not  far  from  the  corner  of  the  mouth.  There  is  a  swelling 
of  the  whole  cheek,  especially  under  the  eye.  The  odor  of  gan- 
grene is  usually  the  first  thing  to  make  clear  the  diagnosis.  Then 
the  gangrene  appears  externally  as  a  black  patch  on  the  cheek,  sur- 
rounded by  a  red  halo. 

XV.  THE  TONSILS  AND  PHARYNX. 

METHOD  OF  EXAMINATION. — Place  the  patient  facing  a  good 
light,  natural  or  artificial.  Ask  him  to  open  his  mouth  without 
protruding  the  tongue.  Ask  him  to  say  "Ah."  Then  gently  press 
down  and  forward  on  the  dorsum  of  the  tongue  (not  too  far  back) 
with  a  spoon  or  tongue  depressor,1  until  a  good  view  of  the  throat 
is  obtained. 

Look  especially  for : 

1.  Inflammations  (redness,  eruptions,  spots,  or  membranes). 

2.  Ulcerations. 

3.  Swellings. 

4.  Reflexes. 

1.  Inflammations. 

(a)  General  redness  means  a  mild  or  early  pharyngitis,  but  may 
precede  severe  diseases  like  diphtheria  and  scarlet  fever. 

1  If  the  patient  is  especially  nervous,  it  is  sometimes  well  to  let  him  press 
down  his  tongue  with  his  own  forefinger. 


THE  HEAD  AND  FACE.  27 

(V)  Yellowish-ivhite  spots  on  the  tonsils,  more  or  less  confluent, 
mean  follicular  tonsillitis  in  the  vast  majority  of  cases,  but  only  by 
culture  can  we  exclude  diphtheria  with  certainty.  Fever  and  head- 
ache are  usually  present. 

(c)  A  membrane,  continuous  and  grayish-white  over  one  or  both 
tonsils,  especially  if  it  extends  to  soft  palate  and  uvula,  means 
diphtheria  in  almost  every  case.1  Rarely  a  similar  membrane  is 
seen  in  streptococcus  throats  with  or  without  scarlet  fever.  Cult- 
ures alone  can  decide. 

(d~)  The  eruptions  of  smallpox  and  chickenpox  may  be  distributed 
in  the  pharynx  as  well  as  over  the  rest  of  the  respiratory  tract. 
They  are  recognized  by  association  with  more  characteristic  skin 
lesions  and  constitutional  signs. 

2.    Ulcerations. 

(a)  Deep  ulcerations  of  the  tonsils  or  soft  palate  are  oftenest 
due  to  syphilis.  Improvement  under  potassium  iodide  and  the 
manifestations  of  syphilis  elsewhere  make  the  diagnosis  possible. 

(6)  Tuberculosis  may  produce  similar  deep  ulcerations,  recog- 
nized by  their  association  with  obvious  tuberculosis  of  the  lung  or 
larynx.  Occasionally  smaller  "miliary"  tubercles,  not  unlike 
"canker  sores,"  are  seen  in  the  tonsillar  region.  Their  chronic 
course  and  the  presence  of  other  tuberculous  lesions  identify  them. 

(c)  Malignant  disease  (oftenest  sarcoma)  may  attack  the  tonsil, 
and  forms  a  rapidly  growing  and  finally  ulcerating  tumor.  No 
other  lesion  of  the  tonsil  grows  so  fast  and  invades  surrounding 
parts  so  extensively  except  abscess;  in  abscess  the  pain,  fever,  and 
constitutional  manifestations  are  far  greater. 

1  T/i  rush,  a  rather  rare  disease  of  ill -nourished  infants,  due  to  a  fungus  of 
the  yeast  order,  may  produce  on  the  pharynx,  tongue,  or  in  any  part  of  the 
mouth,  patches  of  white  membrane.  As  the  disease  is  almost  wholly  local 
and  without  constitutional  manifestations,  it  is  passed  over  briefly  here. 

Streaks  of  mucus  or  bits  of  milk  wugulum  are  sometimes  mistaken  for  a 
membrane. 


28  PHYSICAL  DIAGNOSIS. 


/  3.    Swellings. 

(a)  Chronic  swollen  tonsil  (unilateral  or  bilateral)  without  fever 
or  constitutional  symptoms  represents  usually  the  residual  hyper- 
trophy following  many  acute  attacks  of  tonsillitis  or  may  be  part  of 
the  general  adenoid  hypertrophy  so  common  in  children's  throats. 
Rarely  it  forms  part  of  the  leukaemic  or  pseudo-leuksemic  process. 

(&)  Acute  swollen  tonsil  is  usually  part  of  follicular  tonsillitis  (see 
above),  but  may  occur  without  spots,  and  often  accompanies  scarlet 
fever.  Swelling,  pain  in  swallowing,  and  fever  are  the  essentials 
of  diagnosis.  Our  chief  care  should  be  to  exclude : 

(c)  Tonsillar  abscess  (quinsy  sore  throat).  Here  the  swelling  is 
usually  unilateral  and  greater  than  in  follicular  tonsillitis.  The 
pain,  which  is  often  severe,  is  continuous  and  not  merely  on  swal- 
lowing. Fever,  constitutional  symptoms,  and  swelling  of  the 
glands  at  the  angle  of  the  jaw  are  all  more  marked  than  in  follicu- 
lar tonsillitis.  The  voice  is  nasal  or  suppressed,  and  there  is  often 
salivation.  The  pillars  of  the  fauces  and  the  soft  palate  take  part 
in  the  swelling  and  the  throat  may  be  almost  blocked  by  it.  The 
suffering  increases  until  the  abscess  breaks  or  is  opened.  Fluctu- 
ation is  often  late  and  indefinite,  but  should  always  be  sought  for. 

(fZ)  Retrophari/nyeal  Abscess. — A  swelling  in  the  back  of  the 
pharynx  near  the  vertebrae  occurs  not  infrequently  during  the  first 
year  of  life.  A  peculiar  cry  or  cough,  like  the  bark  of  a  puppy  or 
the  call  of  a  heron,  is  very  often  associated  (the  French  "  cri  de 
canard").  The  parents  are  often  unaware  that  the  throat  is  the 
seat  of  the  trouble,  and  only  digital  examination  proves  the  pres- 
ence of  bulging  and  fluctuation,  usually  on  one  side  of  the  poste- 
rior pharyngeal  wall. 

A  similar  abscess  of  chronic  course  may  complicate  cervical 
caries  (see  below,  page  31). 

(e~)  Swollen  uvula,  with  transparent  oedema  of  its  tip,  often  com- 
plicates a  pharyngitis  or  any  lesion  with  violent  cough.  Elonga- 
tion of  the  uvula  may  bring  it  into  contact  with  the  tongue  and  by 
tickling  excite  cough. 


THE  NECK.  29 

(/")  Perforation  of  the  soft  palate  or  its  adhesion  to  the  back  of 
the  pharynx  means  syphilis  almost  invariably,  and,  as  it  may  be  the 
only  sign  of  an  old  infection,  it  is  a  valuable  piece  of  evidence. 

4.  Reflexes. 

(a)  Lively  or  exaggerated  pharynyeal  reflexes,  such  that  the  pa- 
tient gags  and  coughs  as  soon  as  one  touches  the  dorsum  of  the 
tongue,  are  seen  in  many  nervous  persons  and  in  many  alcoholics 
without  nervousness.  It  is  this  condition,  combined  with  a  smok- 
er's pharyngitis,  that  leads  to  many  cases  of  morning  vomiting  in 
alcoholics. 

(7>)  Diminished  or  absent  reflexes  (with  paralysis  of  the  palate) 
occur  in  postdiphtheritic  neuritis  and  bulbar  paralysis.  Fluids  are  re- 
gurgitated through  the  nose  and  the  voice  has  a  peculiar  intonation. 

To  test  for  paralysis,  ask  the  patient  to  say  "Ah."  In  unilat- 
eral paralysis  one  side  of  the  palate  remains  motionless ;  in  bilate- 
ral paralysis  the  whole  palate  is  still. 

THE  NECK. 

Long,  thin  necks  are  often  seen  in  phthisical  individuals,  and 
short  necks  in  the  emphysematous,  but  nothing  more  than  a  bare 
hint  can  be  derived  from  such  facts.  The  lesions  oftenest  searched 
for  in  the  neck  afre  :  1.  Enlarged  glands  (cervical  adenitis).  2.  Ab- 
scesses and  scars.  3.  Thyroid  tumors.  4.  Pulsations  (see  below, 
page  88).  5.  Torticollis  and  other  lesions  simulating  it.  6.  Tu- 
berculosis of  the  cervical  vertebrae. 

Rarer  lesions  will  be  mentioned  below. 

/.    Chains  of  Enlarged  Glands 

radiate  in  all  directions  from  the  angle  of  the  jaw — upward,  in 
front  of  the  ear  and  behind  it,  forward  along  the  ramus  of  the  jaw, 
and  downward  to  the  clavicle.  The  areas  drained  by  the  different 
groups  overlap  so  much  that  it  is  not  necessary  to  distinguish  them. 


30  PHYSICAL  DIAGNOSIS. 

The  commonest  causes  of  enlargement  are : 

(a)  Tonsillitis  and  other  inflammations  within  or  around  ilic 
mouth  (diphtheria,  the  exanthemata,  "cankers,"  carious  teeth, 
etc.).  Glandular  swellings  due  to  these  causes  are  usually  acute 
and  more  or  less  tender;  most  of  them  disappear  in  a  fortnight  or 
less,  but  some  persist  (without  pain)  indefinitely. 

(6)  Tuberculosis;  long-standing  cervical  adenitis  in  children 
and  young  adults,  with  a  tendency  to  involve  the  skin  and  to  suppu- 
rate, is  usually  due  to  this  cause.  Certain  diagnosis  depends  on 
microscopic  examination,  animal  inoculation,  and  the  tuberculin 
test. 

(c)  Syphilis;  small,  non -suppurating  glands,  occurring  in  the 
neck  and  about  the  occiput  in  adults,  often  accompany  syphilis,  but 
the  diagnosis  depends  on  the  presence  of  unmistakable  syphilitic 
lesions  elsewhere. 

(d)  Hodgkin's  disease;  chronic,  large,  rarely  suppurating  glands 
in  the  neck,  axillae,  and  groins,  with  slight  splenic  enlargement  and 
normal  blood,  suggest  Hodgkin's  disease,  but  microscopic  examina- 
tion is  necessary  to  exclude  tuberculosis.     A  superficial  gland  can 
be  excised  under  cocaine,  with  very  little  pain. 

(e)  Lymphatic  Leukaemia.     No    distinguishing  characteristics 
can  be  found  in  the  glands,  but  any  nodular  enlargement  in  the 
neck  should  lead  us  to  examine  a  film  specimen  of  blood,  and  the 
leukaemio  blood  changes  are  easily  and  quickly  recognized. 

(/")  Malignant  disease  (near  by  or  at  a  distance)  may  enlarge 
the  cervical  glands.  Cancer  of  the  lip  or  tongue,  sarcoma  of  the 
tonsil,  and,  among  distant  lesions,  cancer  of  the  stomach  and  sar- 
coma of  the  lung  have  caused  enlargement  of  these  glands  in  cases 
under  my  observation. 

(<7)  If  the  parotid  gland  alone  is  swollen  and  there  are  fever  and 
pain  on  chewing,  the  case  is  probably  one  of  mumps,  especially  if 
there  are  other  cases  in  the  vicinity.  Malignant  disease  may  also 
attack  the  parotid. 

(Ji)  German  measles  may  be  accompanied  by  swelling  of  the  pos- 
terior cervical  or  occipital  glands  without  the  involvement  of  any 
other. 


THE  NECK. 


31 


II.  Abscess  or  Scars. 

Abscess  or  scars  in  the  sides  and  front  of  the  neck  generally  re- 
sult from  glandular  tuberculosis;  hence  the  presence  of  scars  may 
be  of  value  in  the  diagnosis  of  doubtful  cases  with  a  suspicion  of 
tuberculosis  in  later  life.     Aside 
from  glandular  abscesses  (tuber- 
culous or  septic)  it  is  rare  to  find 
any  suppuration  in  the  neck,  ex- 
cept  in   the  nape,  where  deep, 
septic    abscess    (carbuncle)  and 
superficial    boils    are     common. 
High  Pott's  disease  maybe  com- 
plicated by  abscess  (see  Fig.  18). 

III.    Thyroid  Tumors 

occur  chiefly  in  two  diseases : 

(«)  Simple  goitre  (unilateral 
or  bilateral). 

(&)  Goitre  ivith  exopkthalinos, 
tacit y i-ardia,  and  tremor  (Graves' 
disease). 

The  tumor  may  look  the  same 
in  these  two  diseases  (see  Fig. 
19);  it  varies  in  outline  and  con- 
sistency according  to  the  amount 
of  gland  tissue  and  fibrous  or 

cystic  degeneration  that  is  present.  Owing  to  its  connection  with  the 
larynx  it  moves  up  and  down  somewhat  when  the  patient  swallows, 
but  is  not  attached  to  any  other  structures  in  the  neck.  The  en- 
largement is  often  unilateral  or  largely  so.  If  very  vascular,  the 
tumor  may  vary  greatly  in  size  from  moment  to  moment  or  at 
certain  times  (i.e.,  menstruation,  pregnancy). 

Since  the  normal  thyroid  can  rarely  be  felt,  atrophy  ef  the  gland 
(as  in  myxoedema)  is  unrecognizable. 


FIG.  18.— Cervical  Abscess  in  Pott's  Disease. 
(Bradford  and  Lovett.) 


32 


PHYSICAL   DIAGNOSIS. 


Cancer  or  sarcoma  have  occurred  in  the  thyroid  and  may  be  diffi- 
cult to  distinguish  from  goitre.      Malignant  tumors    are    usually 

painful,  grow  fast,  are  ac- 
companied by  emaciation 
and  anaemia,  are  often 
harder  and  more  nodulated 
than  benign  goitres,  and 
invade  the  neighboring  tis- 
sues and  lymphatics.  His- 
tological  examination 
should  decide  in  doubtful 
cases. 

IV.  Torticollis  (  Wry-neck) 
and  Other  Lesions  Re- 
sembling It.  . 

(a)  Spasm  (tonic,  rarely 
FIG.  i9.-simpie  Goitre.  clonic)  of   the  sterno-mas- 

toid  and  trapezius  may  be 

due  to  irritation  of  the  spinal  accessory  nerve  by  swollen  glands, 
abscess,  scar,  or  tumor,  but 
more  often  occurs  without 
known  cause  ("rheumatic" 
and  "nervous"  cases).  The 
muscle  is  rigid  and  tender. 

(i)  Congenital  torticollis  (a 
counterpart  of  club-foot)  is 
due  to  shortness  of  the  muscle 
without  sjmsm.  It  is  almost 
always  right-sided  and  associ- 
ated with  facial  asymmetry. 

(c)  Dislocation  of  the  upper 
cervical  vertebral  causes  a  dis- 
tortion of  the  neck  much  like 
that  of  torticollis  (see  Fig.  20). 
The  diagnosis  depends  on  the 


FIG.  20.— Dislocation  of  the  Cervical  Vertebrae. 
(Walton.) 


THE  NECK.  33 

history  of  injury,  the  absence  of  true  muscular  spasm,  and  the  x-ray 
picture. 

(c?)  Compensatory  cervical  deviations  :  (1)  When  there  is  marked 
lateral  curvature  of  the  spine,  with  or  ivithout  Pott's  disease,  the 
head  may  be  inclined  so  far  to  the  opposite  side  that  torticollis  is 
simulated  (see  below,  page  71).  (2)  When  the  power  of  the  two 
eyes  is  markedly  different,  as  in  some  varieties  of  astigmatism,  the 
head  may  be  habitually  canted  to  one  side  to  assist  vision.  (3)  In 
some  cases  due  to  none  of  the  above  causes,  habit  or  occupation 
(heavy  loads  on  one  shoulder)  seem  to  produce  the  condition. 

(e)  Forced  attitude  from  cerebellar  disease  may  resemble  torti- 
collis. The  diagnosis  depends  on  the  other  evidences  of  iutracranial 
disease. 

V,    Cervical  Pott's  Disease  (  Vertebral  Tuberculosis) 

has  the  characteristics  alluded  to  below  in  the  section  on  joint  tu- 
berculosis, vi/.,  stiffness  due  to  muscular  spasm,  malposition  of  the 
bones  and  of  the  head,  and  abscess  formation  (see  page  31). 

Diagnosis  depends  on  wry-neck  with  stiffness  of  the  muscles  of 
the  back  and  neck  and  pain  in  the  occiput — a  very  characteristic 
symptom-group.  The  chin  is  often  supported  by  the  hand. 
''Rheumatic"  or  traumatic  torticollis,  however,  may  present  all 
these  symptoms,  and  diagnosis  may  be  impossible  without  the  aid 
of  time  and  therapeutic  tests. 

VI.  Branchial  Cysts  and  Fistulce. 

These,  due  to  persistence  of  parts  of  the  foetal  branchial  clefts, 
are  not  very  uncommon  (see  Fig.  21). 

A  branchial  cyst  is  a  globular  or  ovoid  fluctuating  sac,  hanging 
or  projecting  from  the  side  of  the  neck  or  the  region  of  the  hyoid 
bone,  painless  and  slow  of  growth.  It  may  transmit  the  motions 
of  the  carotids  and  be  mistaken  for  aneurism,  but  has  no  expansile 
pulsation  and  occurs  in  youth,  when  aneurism  is  practically  un- 
known. Some  such  cysts  may  be  emptied  by  external  pressure.1 

'A  patient  of  mine  can  produce  a  gush  of  foul  fluid  in  the  mouth  by 
pressure  over  a  small  cyst  in  the  neck. 
3 


34 


PHYSICAL  DIAGNOSIS. 


Branchial  cysts  may  contain  serous,  mucous,  or  sero-sanguineous 
fluid,  or  hair  and  sebaceous  material,  according  as  their  lining  wall 
is  derived  from  ectoderm  or  entoderm.  Diagnosis  depends  on  the 
position  and  consistency  of  the  growth  and  on  the  results  of  as- 
piration. 

Branchial  fistulce  (congenital)  may  open  externally  in  the  neck, 

and  occasionally  are  com- 
plete from  neck  to  phar- 
ynx. They  may  become 
occluded  and  suppuration 
result. 

VII.   Actinomycosis. 

ActinomycOsis,  though 
it  usually  arises  in  the 
lower  jaw  bone,  may  ap- 
pear externally  in  the 
neck.  A  dense  infiltra- 
tion with  bluish-colored, 
semifluctuating  areas  in 

it,  but  without  any  distinct  lumps  or  sharp  outlines,  is  strongly 
suggestive  of  actinomycosis,  and  should  always  lead  to  a  micro- 
scopic, examination  of  excised  portions  or  of  the  discharge. 

Fistulse  may  form,  but  are  less  common  than  in  tuberculosis, 


FIG.  2 1.— Branchial  Cyst. 


VIII.  A  Cervical  Rib, 

springing  from  the  seventh  cervical  vertebra  and  ending  free  or  at- 
tached to  the  first  thoracic  rib,  appears  in  the  neck  as  an  angular 
fulness  which  pulsates,  owing  to  the  presence  of  the  subclavian  ar- 
tery on  top  of  it.  It  rarely  produces  any  symptoms  and  is  gener- 
ally encountered  when  percussing  the  apex  of  the  lung.  The  bone 
can  be  felt  behind  the  artery  by  careful  palpation  and  demonstrated 
by  radiography.  Pain  or  wasting  in  the  arm,  and  occasionally 
thrombosis  may  occur. 


CHAPTER   III. 
THE  ARMS  AND   HANDS;    THE   BACK. 

THE   AEMS. 

Most  of  the  lesions  of  these  parts  are  joint  lesions  and  are  dealt 
tvith  in  the  section  on  joints.  Others  fall  under  the  province  of  the 
neurologist  or  the  dermatologist,  but  must  be  briefly  mentioned  here. 

/.   Paralysis  of  One  Arm. 

Paralysis  of  most  or  all  the  muscles  of  one  arm  occurs  oftenest 
in:  (a)  Hemiplegia — with  paralysis  of  the  leg  and  often  of  the  face 
on  the  same  side.  (&)  Pressure  neuritis — traumatic  or  from  new 
growths.  (<•)  Obstetrical  paral  i/sis — neuritis  from  injury  during  par- 
turition. (W)  Lead  or  alcoholic  neuritis — extensors  of  wrist  espe- 
cially, and  often  in  both  arms,  (e)  Anterior  poliomyelitis — infantile 
paralysis.  (/)  Hysteria  and  traumatic  neuroses.1 

Pressure  Neuritis. — The  history  of  the  case  is  of  the  greatest  im- 
portance. During  surgical  anaesthesia  the  brachial  plexus  or  the 
musculo-spiral  nerve  may  be  compressed,  and  paralysis  is  noted  as 
soon  as  the  patient  comes  out  of  anaesthesia.  In  a  similar  way  in 
deep  sleep,  especially  drunken  sleep  with  the  arm  hanging  over  a 
bench  or  doubled  under  the  body,  the  nerves  may  be  injured. 
Pressure  from  a  crutch  or  from  the  head  of  the  humerus  in  fractures 
or  dislocations,  or  even  a  violent  fall  on  the  shoulder  without  injury 
of  bones,  may  result  in  a  paralyzed  arm. 

1  Less  common  are  paralyses  due  to  lesions  of  the  arm  centre  in  the  cerebral 
cortex  (tumor,  softening,  cyst,  abscess,  hemorrhage,  thromboses,  or  embol- 
ism). 


36  PHYSICAL  DIAGNOSIS. 

Diagnosis  rests  on  the  history,  and  on  the  fact  that  not  only  the 
muscles  of  the  shoulder  group  and  the  extensors  of  the  wrist  are 
affected,  but  also  the  supinator  longus,  while  in  the  toxic  paralyses, 
especially  lead,  the  supinator  longus  is  spared.  To  test  the  func- 
tion of  this  muscle,  grasp  the  patient's  wrist  with  the  thumb  side 
uppermost,  and  resist  while  he  attempts  to  flex  the  arm  at  the 
elbow.  If  the  supinator  is  intact  it  will  spring  into  relief  on  the 
thumb  side  of  the  forearm. 

Obstetrical  Neuritis.  — In  instrumental  deliveries  or  when  forci- 
ble traction  on  the  child's  arm  has  been  necessary,  with  or  without 
fractures,  a  paralysis  of  the  arm  often  results,  and,  what  is  impor- 
tant, is  often  not  noticed  till  some  years  later,  and  then  thought  to 
have  just  arisen;  thus  it  may  be  mistaken  for  anterior  poliomyelitis 
or  other  lesions. 

Toxic  Neuritis. — Lead  or  alcohol  produces  usually  a  weakness  of 
both  forearms,  especially  the  extensors  of  the  wrist  ("  wrist-drop  "), 
but  one  side  may  be  predominantly  affected  and  other  muscles  are 
involved  in  most  severe  cases.  The  history,  the  other  signs  of  lead 
poisoning,  and  the  soundness  of  the  supinator  longus  distinguish  it 
from  other  paralyses. 

All  these  forms  of  neuritis  are  apt  to  be  accompanied  by  pain, 
anesthesia,  or  parsesthesia,  which  helps  to  distinguish  them  from 
the  cerebral  and  spinal  paralyses  next  described. 

Acute  Anterior  Poliomyelitis. — Paralysis  attacks  a  child  suddenly 
and  without  apparent  cause,  perhaps  after  "a  feverish  turn." 
Either  the  upper  arm  group  (deltoid,  biceps,  brachialis  anticus,  and 
supinator  longus)  or  the  lower  arm  group  (flexors  and  extensors  of 
wrist  and  fingers)  may  be  affected.  The  arm  is  flabby  and  painless, 
the  muscles  waste  rapidly,  and  the  electrical  reactions  show  degen- 
eration, often  within  a  week. 

Hysterical  and  Traumatic  Neuroses. — The  history  and  mode  of 
onset,  the  frequent  association  of  sensory  symptoms  which  do 
not  fit  the  distribution  of  any  peripheral  nerve,  spinal  segment, 
or  cortical  area,  the  normal  reflexes  and  electrical  reactions  dis- 
tinguish most  cases  of  this  type,  but  diagnosis  is  sometimes  impos- 
sible. 


THE  ARMS.  37 

Paralysis  of  both  arms  is  much  less  common  than  paralysis  of 
one  arm,  and  occurs  chiefly  in  poisoning  by  lead  and  in  multiple 
neuritis.  Rarely  it  is  seen  in  the  late  stages  of  chronic  diseases  of 
the  spinal  cord. 

11.    Wasting  of  One  Arm. 

(a)  Rapid  atrophy  occurs  in  all  the  types  of  neuritis  mentioned 
above,  as  well  as  in  poliomyelitis  and  progressive  muscular  atrophy. 
In  the  latter  it  occurs  without  complete  paralysis,  though  the 
wasted  muscles  are,  of  course,  weak.  Progressive  muscular  atro- 
phy usually  begins  in  the  muscles  at  the  base  of  the  thumb  and  be- 
tween it  and  the  index  linger.  Less  often  the  disease  begins  in 
the  deltoid.  In  either  case  the  rest  of  the  arm  muscles  are  later 
involved. 

In  all  the  atrophies  just  mentioned  a  lack  of  the  trophic  or 
nourishing  functions  which  should  flow  down  the  nerve  is  assumed 
to  explain  the  wasting  ("trophic  atrophy").  From  this  we  distin- 
guish the  atrophy  due  simply  to  disuse  of  the  muscles  without  nerve 
lesions. 

(7»)  Slow  atrophy  of  disuse  occurs  in  the  arm  in  hemiplegia,  in- 
fantile or  adult,  and  in  other  cerebral  lesions  involving  the  arm 
centre  or  the  fibres  leading  down  from  it. 

(c)  The  atrophy  often  seen  in  hysterical  cases  is  probably  due  to 
disuse  and  is  similar  to  that  occurring  in  an  arm  that  has  been 
splinted  after  fracture  or  dislocation. 

III.    Contractures  of  the  Arm. 

After  cerebral  lesions  involving  the  arm  centre,  and  in  almost 
any  spinal  or  peripheral  nerve  lesion  which  involves  one  set  of  mus- 
cles and  spares  another,  the  sound  muscles  contract  (or  overact) 
and  permanent  deformities  result.  In  hysteria  similar  contractures 
occur.  Contractures  have  in  themselves  little  or  no  diagnostic 
value,  but  indicate  a  late  and  stubborn  staye  of  whatever  lesion  is 
present. 


38  PHYSICAL  DIAGNOSIS. 

1 V.    (Edema,  of  the  Arm. l 

Causes. — 1.  Thrombosis  of  axillary  or  brachial  vein,  usually 
the  result  of  heart  disease.  2.  Pressure  of  tumors — aneurism,  can- 
cer of  axillary  glands,  Hodgkin's  disease,  sarcoma  of  lung  or  medi- 
astinum. 3.  Nephritis,  when  the  patient  has  lain  long  on  one  side. 
4.  Inflammation,  usually  with  evidence  of  lymphangitis  spreading 
up  the  arm  from  a  septic  wound  on  the  hand. 

The  diagnosis  of  the  cause  of  oedema  is  usually  easy  in  the  light 
of  the  facts  brought  out  by  the  general  physical  examination  (heart, 
urine,  local  lesions,  etc.). 

[The  arteries  of  the  arm  (brachial  and  radial)  are  to  be  investi- 
gated for  changes  in  the  vessels  (see  page  90)  and  for  the  evidence 
given  by  their  pulsations  as  to  the  work  of  the  heart  (see  page  103).] 

V.    Tumors  of  the  Upper  Arm. 

In  the  upper  arm  we  have:  1.  Fatty  tumors.  2.  Sarcoma  of 
the  humerus.  3.  Ruptured  biceps.  4.  Syphilitic  nodes  on  the 
humerus.  5.  Tuberculosis  of  the  humerus.  6.  Gouty  deposits  in 
the  triceps  tendon. 

Fatty  tumors  are  recognized  by  the  history  of  long  duration  and 
very  slow  growth,  by  their  superficial  position,  usually  external  to 
the  muscles,  and  soft,  lobulated  feel. 

•Sarcoma  forms  the  only  large  tumor  springing  from  the  hu- 
merus. It  is  usually  hard  and  obviously  deep  seated  (see  Fig.  22). 

Ruptured  biceps.  The  lower  half  of  the  biceps  projects  sharply 
when  the  muscle  is  contracted,  looking  as  if  the  biceps  had  slid 
down  from  its  normal  site.  This  appearance  suddenly  following  a 
wrench  or  strain  of  the  biceps  is  diagnostic. 

Syphilitic  nodes  are  flattened  elevations  on  the  bone,  usually 
about  the  size  of  a  half-dollar,  and  feel  like  the  callus  after  a  fract- 
ure, but  project  only  from  one  side  of  the  bone.  There  are  pain, 

1  Distinguished,  like  all  oedema,  by  the  fact  that  a  dent  made  by  pressing 
with  the  finger  does  not  at  once  disappear  when  the  pressure  is  removed. 


THE  ARMS. 


39 


especially  at  night,  and  moderate  tenderness.  A  history  or  other 
and  more  characteristic  lesion  of  syphilis  is  necessary  for  diag- 
nosis. 

Tuberculous  lesions1  are   much    more  common  on  the    forearm 


FIG.  22.— Sarcoma  of  Humenis. 

bones,  but  are  occasionally  seen  on  the  humerus  near  the  epiphyseal 
ends.  They  usually  involve  and  perforate  the  skin,  leaving  an  in- 
dolent, suppurating  sinus  leading  to  necrosed  bone.  The  evidence 

1  A  rare  disease  clinically  identical  with  tuberculosis,  but  due  to  a  wholly 
different  organism,  an  animal  parasite  resembling  a  coccidium,  has  been  de- 
scribed by  Rixford,  Gilchrist,  Montgomery,  and  other  Californian  physicians. 


40 


PHYSICAL  DIAGNOSIS. 


of  tuberculosis  in  other  organs  and  the  slow,  "  cold  "  progress  of  the 
lesion  assist  the  diagnosis. 

Gouty  tophi  are  sometimes  seen  along  the  fasciae  covering  the 
triceps  tendon.  They  are  hard  and  painless.  The  diagnosis  de- 
pends upon  the  peculiar  situation  of  the  lesions  and  their  association 
with  other  evidences  of  gout.1 


VI.  Miscellaneous  Lesions  of  the  Forearm. 

Bowing  of  the  forearm  bones  occurs  in  rickets  and  in  Paget's  dis- 
ease (see  Fig.  204).  TfTe  lesions  in  the  other  parts  of  the  body  make 

the  diagnosis  clear. 

Local   lesions  of   the  bones  of  the 
forearm    are   chiefly    tuberculosis    and 
syphilis,  both  of  which  have  been  suf- 
ficiently described  in  the  last  section. 
In  the  wrist  bones  we  find: 

1.  Rachitic  enlargement  of  the  epi- 
pltyses.     In  rickets  the  terminal    epi- 
physes  at  the   wrists  take  part  in  the 
general  epiphyseal  enlargement  so  com- 
mon in  the  disease.     The  diagnosis  is 
easy,  for  there  is  no  other  disease  of 
infancy  producing  general  enlargement 
of  the  epiphyses  (see  Fig.  23). 

2.  Hypertrophic    pulmonary     osteo- 
arthropathy  (Figs.  24,  25,  and  26).     An 
enlargement  of  the  lower  ends  of  the 
radius  and  ulna,  with  clubbing  -of  the 
fingers  (see  below,   page  47),  is  recog- 
nized by  its  association  with  pulmonary 

or  pleural  diseases  of  many  years'  duration  (chrome  bronchitis,  em- 
pyema).  V 

3.  Acromeyalia  (see  page  9)  affects  chiefly  the  bones  and  soft 
tissues  of  the  hand. 

1  Bursitis  over  the  olecranon  ("miner's  elbow")  produces  a  tender  fluctu- 
ating swelling  over  the  tip  of  the  elbow. 


FIG.  23.— Rachitic  Epiphysitis. 


THE   HANDS.  41 

4.  HypertrophiCj   at  rustic,   or  tuberculous  disease  of   the  wiist- 
joint   will   be    described   below    (see    Examination  of    the   joints, 
page  486). 

5.  "  Weeping  sinew  "  or  "ganglion  "  (tenosynovitis)  forms  a  fluc- 
tuating, spindle-shaped  swelling  along  one  of  the  tendons  of  the 


Fie;.  24. — Ilypertropliic.  Pulmonary  Osteo-arthropathy.     (Thayer.) 

wrist,  slow  and  almost  painless  in  its  course.  It  may  be  tubercu- 
lous, in  which  case  the  sac  is  generally  divided  into  several  parts 
("compound  ganglion")  ;  bacilli  may  occasionally  be  demonstrated 
iii  the  exudate. 

THE   HANDS. 

I.  EVIDENCE  OF  OCCUPATION. — The  horny,  stiffened  hands  of 
the  "  sou  of  toil,"  the  stains  of  paint  in  house  painters,  the  flat- 
tened, calloused  finger-tips  of  the  violinist,  the  worn  fingers  of  the 


42 


PHYSICAL  DIAGNOSIS. 


sewing  woman,  afford  us  items  of  infprmation  which  are  sometimes 
useful  and  worth  a  rapid  glance  in  routine  examination. 

II.  TEMPERATURE  AXD  MOISTURE. — (a)  The  cold,  moist  hand 
is  most  commonly  felt  in  "nervous"  people    under  forty.      It  is 

almost  never  seen  in  heart  dis- 
ease, which  its  possessor  often 
fears,  and  does  not  mean 
"poor  circulation,"  but  vaso- 
motor  disturbances  of  neuro- 
tic origin. 

(&)  Cold,  dry  extremities — 
hands,  feet,  nose,  ears — may 
mean  simply  fatigue,  expos- 
ure to  low  temperature,  or 
insufficient  exercise;  but  in 
the  course  of  chronic  disease 
they  usually  mean  weakness 
of  the  heart,  and  hence  are 
serious. 

(c)  Warm,  moist  hands 
are  felt  in  Graves'  disease  (ex- 
ophthalmic goitre),  and  if  the 
warmth  and  moisture  are 
present  most  of  the  time  and 
not  only  as  a  temporary  phase 
— e.y.,  after  violent  exercise 
— this  disease  is  strongly  sug- 
gested, and  a  search  for  trem- 
or, rapid  heart,  goitre,  and 
bulging  eyes  should  be  made. 
III.  MOVEMENTS  OF  THE 
HANDS. — (a)  The  manner  of 
shaking  hands  gives  us  vague 
but  useful  impressions  of  the 

patient's  temperament.     The  nervous,  cramped,  half-opened  hand, 
which  never  really  grasps'  and  gets  away  as  soon  as  possible;  the 


Fif!.  2.').-  Radiographs  of  the  Hand  and  Arm  of 
u  Case  of  Hypertrophic  Pulmonary  Osteo- 
arthropathy  (the  left  figure)  compared  with 
the  hand  and  arm  of  a  normal  individual  of 
the  same  height  (the  right  figure).  Note  espe- 
cially the  thickening  of  the  radius  and  ulna. 
(Thayer.) 


THE  HANDS. 


43 

of 


firm,  hearty    grasp;    the  limp,   "wilted"  hand — furnish   hints 
character  that  every  physician  must  take  account  of. 

In  fevers  or  toxsemic;  states  (typhoid,  alcoholism)  there  are  two 
sets  of  movements  which  recur  so  often  that  names  have  been  given 
them,  viz.  :  1.  Carphologia — picking  and  fumbling  at  the  bed 


FIG.  26.— Radiograph  of  the  Wrists  in  Hypertrophic  Pulmonary  Osteo-arthropathy.    (v.  Ziems- 

sen's  Atlas.) 


clothes.  2.  Subsultus  tendinum — involuntary  twitching  and  jerking 
of  the  tendons  iu  the  wrist  and  on  the  back  of  the  hand,  usually 
associated  with  tremor  and  carphologia. 

(I}  Tremor  of  the  Hands. — To  test  for  ordinary  tremor,  we  ask 
the  patient  to  extend  and  separate  his  lingers  widely.  The  motions 
are  then  apparent. 

Causes:    1.  Nervousness,  cold,  or  old  ;*ge.      2.   Fever  and  tox- 


44  PHYSICAL  DIAGNOSIS. 

aemia.  3.  Alcohol  (less  often  lead,  tobacco,  morphine,  or  other 
drugs).  4.  Graves'  disease.  5.  Paralysis  agitans.  6.  Multiple 
sclerosis.  7.  Hysteria. 

Most  of  these  tremors  need  no  comment.  The  intention  tremor 
of  multiple  sclerosis  (sometimes  seen  also  in  hysteria)  is  exagger- 
ated into  coarse  shaking  movements  when  the  patient  tries  to  pick 
up  a  pin,  drink  a  glass  of  water,  or  do  any  other  act  calling  for  the 
volitional  coordination  of  the  small  hand  muscles.  In  the  presence 
of  such  a  tremor  we  should  look  for  nystagmus  (see  above,  page  16), 
a  spastic  gait  (see  page  508),  and  a  slow,  staccato  speech.  This 
group  of  symptoms  suggests  multiple  (or  insular)  sclerosis. 

In  direct  contrast  with  this  is  the  pill-rolling  tremor  of  paralysis 
agitans,  which  usually  ceases  during  voluntary  movements.  The 
thumb  and  forefinger  are  near  or  touch  one  another,  and  move  as 
if  they  were  rolling  a  bread-pill.  This  tremor  is  usually  associated 
with  an  immovable,  expressionless  face,  a  stiffened  neck  and  back, 
and  a  peculiar  attitude  and  gait  (see  below,  page  509). 

The  other  varieties  of  tremor  can  usually  be  recognized  by  the 
history  and  associated  symptoms. 

(c)    Spasms  or  coarse  twitchinys  of  the  hand  due  to : 

1.  Jacksonian  epilepsy — convulsive  attacks  which  begin  in  and 
may  remain  confined  to  one  set  of  muscles,  often  preceded  by  prick- 
ling or  other  parsesthesia  of  the  part  affected,  but  icithont  loss  of  con- 
sciousness.    These  muscle  spasms  are  due  usually  to  an  irritation  of 
the  corresponding  motor  area  in  the  cortex  cerebri  (tumor,  soften- 
ing, chronic  meningitis,  etc.),  but  may  also  occur  in  uraemia  and 
dementia  paralytica.     Coma  and  general  spasms  may  follow. 

2.  Professional   Spasm. — Writers,     violin-players,   and    others 
who  use  one  set  of  muscles  continually  are  often  attacked  with 
painful  cramps  in  the  muscles  used  ("  writer's  cramp  ").     Weakness 
or  semi-paralysis  of  the  muscles  may  follow. 

3.  Chorea   and     Choreiform    Movements. — True,    acute    chorea 
(Sydenham's)  occurs  in  children  between  five  and  fifteen,  generally 
in  those  who  have  joint  troubles  or  heart  disease,  and  ends  in  eight 
or  ten  weeks.      The  hands  are  usually  affected  first,   and  their 
movements  are  like  those  of  restlessness  and  are  quasi-purposive, 


THE  HANDS 


45 


i.e.,  movements  that  might  have  been  made  intentionally,  though 
they  are  not.  At  first  sight  one  would  surely  think  the  child  was 
simply  fidgety. 

Similar  movements  occur  in  pregnant  women  or  sometimes  after 
parturition,  but  the 
type  is  much  severer 
and  is  apt  to  be  asso- 
ciated with  maniacal 
symptoms. 

Post-hemiplegic 
chorea  refers  to  similar 
movements  in  the 
paralyzed  hands  of 
hemiplegic  cases  (chil- 
dren or  adults). 

•In  hysteria  or  by  a 
sort  of  psychic  con- 
tagion similar  move- 
ments are  sometimes 
taken  up  in  schools 
and  institutions,  and 
last  till  their  cause 
is  understood  and  re- 
moved. 

Chronic  choreiform 
movements  occur  also 
in  the  rarer  congeni- 
tal forms  of  paral- 
ysis with  or  without 
idiocy. 

4.  Athetosis  (see 
Fig.  27)  means  slow 
twisting  and  bending 
movements  of  the 

fingers,  quite  involuntary  and  always  secondary  to  organic  cerebral 
lesions  (hemiplegia,  infantile  cerebral  paralysis). 


FIG.  27.  — At 


Successive  positions   of    the    bands. 
(Curschmann.) 


46  PHYSICAL  DIAGNOSIS. 

5.  Tetany  (see  Fig.  28) — a  peculiar  spasm  of  the  hands  (often 
of  the  feet  as  well),  occurring  in  the  course  of  diseases  of  the 

stomach  and  intestine  in  chil- 
dren, in  nursing  women, 
after  gastric  lavage,  and  after 
thyroidectouiy,1  usually  last- 
ing minutes  or  hours — rarely 
days. 

IV.   DEFORMITIES  OF  THE 
HANDS. 

1.  "Claw    hand"    results 
from    paralysis  of  the  inter- 
ossei    and    lumbricales    with 
contractures,  and  occurs  when 
the  median  or  ulnar  nerves  are 
paralyzed  and  in  progressive 
muscular    atrophy,     syringo- 
myelia,     and    chronic    polio- 
myelitis. 

2.  "Flipper    hand"    (see 
Fig.  29),  a  common  result  of 
the  contractures  in  late  cases 
of  atrophic  arthritis.      Other 
deformities  of  the  fingers  are 
common  in    this  disease  and 

FiO.  28.-Tetany.    (Masland.)  jn  gQut  ^QQ  ^low,  page  5Q.J). 

3.  " Hemiplegic  hand,"  a 
result  of  the  contractures  following  hemiplegia  from  any  cause. 

4.  Myxcedema  results  in  thickening  and  coarsening  of  the  tis- 
sxies  of  the  hand  ("  spade  hand ")  without  bony  enlargement ;  but 
the  spade  hand  is  a  fairly  common  type  without  myxoedema,  and 
one  needs  to  see  it  rapidly  develop  in  connection  with  other  inyxoe- 
dematous  lesions  before  it  can  have  diagnostic  significance.  (The 
same  is  true  of  the  myxcedeinatous  face.)  (See  Fig.  30.) 

1  When  the  parathyroid  glands  are  accidentally  removed. 


THE  HANDS.  47 

5.  Acromegalia  produces  general  enlargement  of  the  bones  and 
other  tissues  of  the  hands  and  feet. 

6.  Pulmonary    Osteo-arthropathy. — Any   long-standing   disease 
of  the  heart,  lungs,  or  pleura  may  be  followed  by  this  peculiar  hy- 
pertrophic  change  in  all  the  tissues  of  the  extremities.     Mild  forms 
produce  "  clubbed  fingers,"  a  bulbous  enlargement  of  the  finger-tips 
with  double  curvation  of  the  nails,  lateral  and  antero-posterior^see 


FIG.  29.- Atrophic  Arthritis  with  "Flipper  Hand." 

Fig.  31).     In  severer  forms  the  bones  of  the  hand  and  wrist  are  also 
considerably  enlarged  (see  Figs.  25  and  26). 

7.  Heberden's  nodes,  later  described  under  the  head  ,of  hyper- 
trophic  arthritis,  are   here   pictured    (Fig.   32).     The    distinction 
from  (jout  has  already  been  referred  to  (page  505). 

8.  Atrophic  arthritis  (Fig.  29)  (further  described  on  page  498) 
presents  its  most  typical  lesions  in  the  hands  and  wrists.     The  con- 
striction line  opposite  the  articulation  is  observed  in  late  cases,  but 

1  Clubbed  fingers  are  occasionally  seen  in  a  variety  of  other  diseases:  e.g., 
hepatic  abscess,  nephritis;  and  even  in  apparently  healthy  persons. 


48 


PHYSICAL   DIAGNOSIS 


ordinarily  multiple  spindle-joints  symmetrically  arranged  are  all 
that  we  see.  The  boggy  feel,  the  trophic  disturbances,  and  the 
chronic  course  are  diagnostic. 

9.   Syphilitic  and  tuberculous  dactylitis  (see  Fig".  33),  seen  as  a 


FIG.  30.— Spade  Hand  in  MyxoRdema. 


rule  in  young  children,  are  not  distinguished  from  each  other  by 
the  physical  signs.     Diagnosis  rests  upon  the  history,  the  course, 


THE  HANDS.  49 

the  results  of  giving  tuberculin  or  potassic  iodide,  and  the  evidence 
of  syphilitic  or  tuberculous  lesions  elsewhere.  In  either  disease  we 
have  a  chronic,  almost  painless,  boggy,  red  enlargement  of  one 
phalanx,  or  more,  due  to  an  indolent  inflammation  which  starts 
from  the  bone  or  periosteum  and  usually  burrows  to  the  surface,  to 
produce  a  chronic  discharging  sinus  or  ulcer. 

10.   Raynaud' ' s  disease  attacks  the  fingers  more  often  than  any 
other  part.     Osier  distinguishes  three  grades  of  intensity :  A.  Local 


FIG.  31. — Clubbed  Fingers. 

syncope  ("  dead  fingers)  following  exposures  to  slight  cold  or  emo- 
tional strain.  The  fingers  become  white  and  cold.  The  condition 
usually  passes  off  in  an  hour  or  two.  From  similar  causes  we  may 
have:  B.  Local  asphyxia  ("chilblains"),  producing  congestion  and 
swelling  witli  or  without  pain  and  stiffness  and  with  heat  or  coldness 
of  the  part.  C.  Local  or  symmetrical  gangrene.  If  local  asphyxia 
persists,  gangrene  results.  (See  also  under  Erythromelalgia,  p. 
402.) 

4 


50  PHYSICAL  DIAGNOSIS. 

11.  Morvan's  Disease. — As  a  part  of   syringomyelia    multiple 
arthropathies  (atrophic  arthritis)  and  painless  felons  may  develop 


FIG.  32.— Heberden's  Nodes. 


in  the  hands  (see  Fig.  34).     The  appearances  may  strongly  suggest : 
12.  Leprosy,  in  which  there  is  likewise  anaesthetic  necrosis  of 


FIG.  33.— Tuberculous  Dactylitis. 


THE  HANDS. 


51 


phalanges,  but  the  two  diseases  can  usually  be  distinguished  by  a 
study  of  the  lesions  and  symptoms  in  other  parts  of  the  body. 

13.   Dxpuytreri's  contraction  of  the  palmar  fascia  is  commonest 


FIG.  34.— Morvan's  Disease. 


in  adult  men,  and  gradually  produces  a  permanent,  painless  flexion 
of  the  little  finger  in  one  or  both  hands.  A  tense  band  is  felt 
in  the  palm.  The  ring  finger  may  also  be  affected;  less  often 


52 


PHYSICAL  DIAGNOSIS. 


the    others.     If   burn    and    felon    are    excluded,  the    diagnosis  is 
obvious. 

THE  NAILS. 

1.  The    nutrition  of  the  nails  suffers  in  chronic  skin  diseases, 
in  myxoadema,  in  many  nerve  lesions  (neuritis,  hemiplegia,  syringo- 

myelia,  etc.),  dementia  paralyt- 
ica;  also  in  atrophic  arthritis. 

2.  A     transverse    ridye    and 
groovo  on  the  nails  often  form 
when   their   growth  is  resumed 
after    an    acute    illness.       The 
movement  of  this  ridge  from  the 
matrix  to  the  free  edge  is  said  to 
take  about  six  months  (see  Fig. 
35). 

3.  Hang-nails  possess  a  cer- 
tain   medical    interest,    because 
in  some  individuals  they  become 
sore  when  the  general  condition 
is  below   par,    and  constitute  a 

FIG.  35.— Grooved  Nails  after  Acute  illness.       rough  index  of  the  degree  of  re- 
sistance to  infection.     They  may 
become  infected  and  lead  on  to  suppuration  (paronychia}. 

4.  Indolent  sores  around  the  nail  should  rouse  the  suspicion  of 
tuberculosis  or  syphilis,  especially  in  a  child. 

5.  (a)  Cyanosis,  the  slatey  or  purplish-blue  color  of  venous  con- 
gestion,  can    be   well    seen    in    the  nails.      (6)   Anosmia,   if  well 
marked,  blanches  the  tint  of  the  tissues  seen  through  the  nail,  but 
the  diagnosis  should  invariably  be  confirmed  by  a  haemoglobin  esti- 
mate. 

6.  Incurvation  of  the  nails  has  already  been  referred  to  as  a  part 
of  the  condition  known  as  "clubbed  fingers  "  (page  47). 

7.  Capillary  pulse  (see  below,  page  91). 


THE  BACK.  53 


THE   BACK. 

The  evidences  of  spinal  tuberculosis,  spinal  curvature,  and  of 
the  spinal  form  of  hypertrophic  arthritis  will  be  described  later 
(pages  491  and  504). 

1.   Stiff  Buck. 

"  Stiff  back  "  may  be  due  not  only  to  the  joint  troubles  just 
mentioned,  but  also  and  more  commonly  to  lumbago,  a  painful 
affection  of  the  lumbar  muscles  without  known  pathologic  basis. 
Clinically  it  is  characterized  by  pain  Avheu  the  muscles  are  used,  as 
in  bending  forward  to  tie  one's  shoes  and  in  recovering  the  upright 
position.  There  is  no  bony  soreness,  and  sideways  bending  is  usu- 
ally freer  than  in  hypertrophic  arthritis.  The  pain  of  lumbago 
does  not  radiate  around  the  chest  or  down  the  legs,  and  is  not  espe- 
cially aggravated  by  coughing  or  sneezing,  but  it  sometimes  extends 
down  low  into  the  fascia  of  the  lumbar  muscles  over  the  sacrum. 
The  age  of  the  patient  (usually  over  thirty)  distinguishes  most  cases 
of  lumbago  from  spinal  tuberculosis. 

11.    Sacro-iliac  Disease. 

Tuberculosis  of  this  joint  has  long  been  known  and  calls  atten- 
tion to  its  presence  by  pain,  psoas  spasm,  and  a  limp.  If  the  wings 
of  the  ilium  are  forcibly  pressed  together,  the  pain  in  the  joint  is 
much  increased.  Abscess  formation  is  often  the  first  distinctive 
sign.  The  motions  at  the  hip-joint  are  not  restricted  and  the  local 
signs  of  vertebral  caries  are  absent.  The  duration  of  the  disease 
and  the  formation  of  abscess  distinguish  it  from  other  lesions  of  the 
sacro-iliac  joint. 

Goldthwaite '  has  recently  shown  that  the  sacro-iliac  joint  is 
subject  to  most  of  the  diseases  of  other  joints,  and  that  some  (e.g., 
hypertrophic  arthritis)  are  not  at  all  uncommon  there.  Many  of 
the  pains  in  the  back  complained  of  by  women  during  menstruation 

'Goldthwaite:  Boston  Medical  and  Surgical  Journal,  March  9th,  1905. 


54  PHYSICAL  DIAGNOSIS. 

or  in  pelvic  disorders  are  referred  precisely  to  the  sacro-iliac  articu- 
lation and  are  probably  due  to  lesions  of  that  joint.  ]\i:uiy  cases 
diagnosed  as  "lumbago"  are  probably  due  to  one  or  another  sacro- 
iliac  lesion.  The  subject  is  a  new  but  very  fruitful  one. 

III.   Spinal  Curvatures. 

Diagnosis  is  not  difficult,  provided  we  are  led  to  examine  the 
back  at  all. 

(a)  Kyphosis  or  backward  convexity  of  the  spine,  if  sharply  an- 
gular, means  Pott's  disease  (tuberculosis).  If  the  curve  is  gentle 
and  gradual  it  may  be  due  to  "round  shoulders,"  to  hypertrophie 
arthritis,  to  emphysema,  Paget's  disease,  or  rickets.  The  rachitic 
curve  is  flaccid,  is  due  simply  to  muscular  weakness,  and  is  asso- 
ciated with  other  evidences  of  rickets.  In  emphysema  and  Paget's 
disease  the  kyphosis  goes  with  the  other  signs  of  those  diseases. 
In  hypertrophie  arthritis  the  curve  is  rigid,  irreducible,  and  usually 
painless.  "Round  shoulders"  can  be  straightened  by  muscular 
exertion,  and  represent  a  habit  of  posture. 

(£)  Lordosis,  an  exaggeration  of  the  normal  forward  convexity 
of  the  lumbar  spine,4s  seen  in  tuberculosis  of  the  hip  or  spine,  in 
paralysis  of  the  dorsal  or  abdominal  muscles  (especially  muscular 
dystrophy),  and  in  abdominal  tumors  (pregnancy),  which  need  to 
be  counterbalanced  by  backward  bending. 

(c)  Scoliosis  is  a  combination  of  lateral  curvature  with  twisting 
of  the  spine.  In  slight  or  doubtful  cases  the  tips  of  the  spinous 
processes  should  be  marked  with  a  colored  pencil,  which  makes  the 
deviation  easily  visible.  Severe  cases  cannot  be  mistaken. 

IV.    Tumors  of  the  Back. 

(a)  Aneurism  of  the  descending  aorta  may  point  in  the  back 
near  the  angle  of  the  left  scapula  (see  below,  page  289).     It  is  the 
only  pulsating  tumor  of  this  region. 

(b)  Perinephritic  abscess  usually  points  between  the  crest  of  the 
ilium  and  the  twelfth  rib,  a  few  inches  from  the  spine  (see  page  418). 


THE  BACK.  55 

(c)  Tuberculous  abscess  ("  cold  abscess  "),  originating  in  verte- 
bral tuberculosis,  may  point  in  the- same  region,  though  more  often 
it  follows  down  the  sheath  of  the  psoas  and  points  near  Poupart's 
ligament.     "  Cold  abscess,"  starting  from  a  necrosed  rib,  is  often 
seen  in  the  back.     The  probe  leads  to  dead  bone  at  the  end  of  the 
sinus.     Microscopic  examination  of  excised  pieces  is  the  only  way 
of  excluding  actinomycosis,  though  this  disease  is  less  apt  to  form 
sinuses. 

(d)  Sarcoma  of  the  scapula,  the  only  tumor  of  the  scapula  that 
is  often  seen,  occurs  in  children  and  rarely  after  the  second  decade. 
With  a  solid,  nearly  painless  tumor  of  this  bone  in  a  child,  sarcoma 
should  always  be  suspected.     Benign  exostoses  are  possible,  but 
usually  occur  later  in  life.     Histological  examination  will  decide. 

(e)  Epithelioma,  arising  from  the  skin  of  the  back,  presents  the 
ordinary  evidences  of  this  form  of  cancer. 

V.   Prominent  Scapula. 

This  is  due  usually  to  : 

(a)   Lateral  curvature  of  the  spine  (see  above). 

(6)  Serratus  paralysis^  recognized  by  the  startling  prominence 
of  the  scapula  if  the  patient  pushes  forward  with  both  hands  against, 
resistance  ("angel-wing"  scapula). 

VI.    Spina  Bifida. 

A  congenital,  saccular  tumor,  connecting  through  a  bony  defect 
with  the  interior  of  the  spinal  canal  at  any  point  between  the  occi- 
put and  the  sacrum;  nine-tenths  of  all  cases  occur  in  the  lowest 
third  of  the  spinal  column.  There  is  no  other  congenital  tumor  in 
this  position  communicating  with  the  spinal  canal. 

In  the  sacral  region  there  are  other  congenital  tumors,  dermoid 
cysts,  lipomata,  and  others.  Their  nature  can  be  learned  only  by 
incision,  but  they  are  all  distinguished  from  spina  bihda  by  the  lack 
of  communication  with  the  spinal  canal. 


THE    CHEST. 

INTRODUCTION. 
I.  METHODS  OF  EXAMINING  THE  THORACIC  OKGANS. 

To  carry  out  a  thorough  examination  of  the  chest  we  do  five 
things:  1.  We  look  at  it;  technically  called  "inspection."  2.  We 
feel  of  it;  technically  called  "palpation."  3.  We  listen  to  the 
sounds  produced  by  striking  it;  technical!}"  called  "percussion." 
4.  We  listen  to  the  sounds  produced  within  it  by  physiological  or 
pathological  processes;  technically  called  "auscultation."  5.  We 
study  pictures  thrown  on  the  fluoroscopic  screen  or  on  a  photo- 
graphic plate  by  the  Roentgen  rays  as  they  traverse  the  chest ; 
technically  called  "radioscopy." 

Measuring  the  dimensions  or  the  movements  of  the  chest  ("men- 
suration ")  is  often  mentioned  as  co-ordinate  with  the  above  meth- 
ods, but  it  yields  very  little  information  of  practical  value,  and  is 
at  present  very  little  used. 

Without  some  knowledge  of  the  regional  anatomy  of  the  chest 
no  intelligent  investigation  of  the  condition  of  the  thoracic  organs 
can  be  carried  on.  Accordingly,  I  shall  begin  by  recalling  very 
briefly  some  of  the  most  essential  anatomical  relations. 

II.  REGIONAL  ANATOMY  OF  THE  CHEST. 

It  seems  to  me  a  mistake  to  divide  the  chest  into  arbitrary  por- 
tions and  to  describe  physical  signs  with  reference  to  such  division. 


.INTRODUCTION. 


57 


The  seat  of  any  lesion  can  best  be  described  by  giving  its  relation 
to  the  clavicle,  sternum,  or  ribs  on  the  front  and  sides  of  the  chest, 
and  to  the  scapulae  and  ribs  behind.  Thus  we  may  speak  of  rales 
as  heard  "above  the  left  clavicle  in  front,"  "below  the  right  scap- 
ula behind,"  "between  the  seventh  and  ninth  ribs  in  the  axilla," 
and  so  on.  When  we  want  to  state  more  exactly  what  part  of  the 
axilla  anteroposteriorly  is  affected,  we  may  refer  to  the  "mid-axil- 
ary  line  "  (see  Fig.  36) ;  or  better,  we  may  place  the  lesion  by  meas- 
uring the  number  of  centimetres  or  inches  from  the  median  line  of 
the  sternum.  In  a  similar  way  the  place  of 
the  apex  impulse  of  the  heart  (whether  in 
the  normal  situation  or  farther  toward  the 
axilla)  can  be  determined  by  measuring  from 
the  median  line  of  the  sternum.  Measure- 
ments referring  to  the  nipple  are  entirely 
useless  in  women  and  not  very  reliable  in 
men.  It  is  better  to  measure  as  above. 

If,  then,  we  confine  ourselves  chiefly  to 
the  bones  of  the  chest  as  landmarks,  and 
fix,  with  reference  to  them,  the  position  of 
any  portion  of  the  internal  organs  which  we 
desire  to  study,  it  becomes  unnecessary  to 
memorize  any  technical  terms  or  to  learn 
the  position  of  any  arbitrary  lines  and  divi- 
sions such  as  are  frequently  forced  upon  the 
student.  The  only  points  which  it  is  neces- 
sary to  memorize  once  for  all  are  : 

1.  The  position  of  the  heart,  lungs,  liver, 
and  spleen  with  reference  to  the  bones  of  the 
chest. 

2.  The  position  of  certain  points  which 
experience     has  taught    us    have,  a    certain 
value  in  physical  diagnosis.     I  mean  (a)  the 
so-called  "  valve  areas  "  of  the  heart,  which 

do  not  correspond  to  the  actual  position  of  the  valves,  for  reasons 
to  be  explained  later  on,  and  (&)  the  percussion  outlines  of  the 


FIG.  36.— The  Mid-Axillary 
Line. 


58  PHYSICAL  DIAGNOSIS. 

heart,  liver,  and  spleen.  These  outlines  do  not  correspond  in  size 
with  the  actual  dimensions  of  the  organs  within,  yet  there  is  a 
definite  relation  between  the  two  which  remains  relatively  constant, 
so  that  we  can  infer  the  size  of  the  organ  itself  from  the  outlines 
which  we  determine  by  percussion.  The  position  of  the  organs 
themselves  is  shown  in  Figs.  37,  38,  and  39.  It  will  be  noticed  in 


Upper  lobe  of  left 
lung. 

i  i  /  Av^^nr^±^A"'  \  \  \ 

Bight  lung. 
Right  auricle.  — 1 i-ft&:^=3sL\:  XXJ\lL<#Ul '        Left  ventricle. 

Lower  lobe  of  left 

_  _  lung. 

Liver. 

w^-^m — 

~    Stomach. 


FIG.  37.  -Position  of  the  Heart,  Lungs,  Liver,  and  Stomach.  The  dotted  lines  correspond  to  the 
outlines  of  the  lung ;  the  heavy  continuous  line  represents  the  heart ;  while  the  position  of 
the  liver  and  of  the  lower  border  of  the  stomach  Is  indicated  by  light  continuous  lines.  The 
ribs  are  numbered. 


Fig.  37  that  the  lungs  extend  up  above  the  clavicles  and  overlap 
the  liver  and  the  heart — facts  of  considerable  importance  in  the 
physical  examination  of  these  organs,  as  will  be  later  seen.  It 
is  also  to  be  noticed  how  small  a  portion  of  the  stomach  is 
directly  accessible  to  physical  examination,  the  larger  part  of  it 
lying  behind  the  ribs  and  covered  by  the  liver.  The  normal  pan- 
creas and  kidneys  are  practically  inaccessible  to  physical  examina- 
tion. 

The  percussion  outlines — corresponding   to    those    portions  of 
the  heart,   liver,  and  spleen  which  lie  immediately  beneath   the 


INTRODUCTION. 


59 


\ 


^,.  Upper  lobe. 


^.,  Lower  lobe. 


Spleen. 

Lower  lobe. 


Upper 
lobe. 


Middle 
lobe. 


_  Liver 


FIG.  38.— Position  of  the  Left  Lung  from  the       FIG.  39.— Position  of  the  Right  Lung  frum  the 
Sides  and  of  the  Spleen.  Side,  and  of  the  Liver. 

chest  walls — will  be  illustrated  in  the  section  on  Percussion  (see 
page  118). 


CHAPTER   IV. 

TECHNIQUE  AND  GENERAL   DIAGNOSIS 

INSPECTION. 

MUCH  may  be  learned  by  a  careful  inspection  of  all  parts  of  the 
chest,  but  only  in  case  the  clothes  are  wholly  removed.  A  good 
light  is  essential,  and  this  does  not  always  mean  a  direct  light ;  for 
example,  when  examining  the  front  of  the  chest  it  is  often  better 
to  have  the  patient  stand  with  his  side  to  the  window  so  that  the 
light  strikes  obliquely  across  the  chest,  accenting  every  depression 
and  making  every  pulsation  a  moving  shadow.  In  searching  for 
abnormal  pulsations,  this  oblique  light  is  especially  important. 

In  examining  the  thorax  we  look  for  the  following  points : 

1.  The  size. 

2.  The  general  shape  and  nutrition. 

3.  Local  deformities  or  tumors. 

4.  The  respiratory  movements  of  the  chest  walls. 

5.  The  respiratory  movements  of  the  diaphragm. 

6.  The  normal  cardiac  movements. 

7.  Abnormal  pulsations  (arterial,  venous,  or  capillary). 

8.  The  peripheral  vessels. 

9.  The  color  and  condition  of  the  skin  and  mucous  membranes 

10.  The  presence  or  absence  of  glandular  enlargement. 

I.   SIZE. 

Small  chests  are  seen  in  patients  who  have  been  long  in  bed 
from  whatever  cause ;  also  in  those  who  have  suffered  in  infancy 
from  rickets,  adenoid  growths  in  the  naso-pharynx,  or  a  combina- 
tion of  the  two  diseases.  Abnormally  large  chests  are  seen  chiefly 
in  emphysema.  Of  course  the  chests  of  healthy  individuals  vary 


INSPECTION. 


61 


a  great  deal  in  size  at  any  given  age,  and  I  have  been  referring  in 
the  last  sentences  only  to  variations  greater  than  those  normally 
found. 

II.   SHAPE. 

There  are  marked  differences  in  shape  between  the  child's  and 
the  adult's  chest  in  health.     A  child's  trunk,  as  compared  with 


FIG.  40.— Funnel  Breast. 

that  of  an  adult,  is  far  more  nearly  cylindrical;  that  is,  the  antero- 
posterior  diameter  is  nearly  as  great  as  the  lateral.  The  adult's 
chest  is  distinctly  flattened  from  before  backward,  although  indi- 
vidual variations  in  this  respect  are  considerable,  as  Woods  Hutch- 
in  son  has  shown. 

In  childhood  the  commonest  pathological  modifications  are  due 


62 


PHYSICAL  DIAGNOSIS. 


to  adenoids  or  to  rickets;  in  middle  and  later  life  to  emphysema, 
phthisis,  or  old  pleuritic  disease 

(«)  The  Rachitie  Chest 

The  sternum  generally  projects  ("pigeon  breast"),  but  in  some 
cases,  especially  when  rickets  is  combined  with  adenoid  hyper- 
trophy, there  may  be  a  depression  at  the  root  of  the  sternum  re- 
sulting in  the  condition  known  as  "funnel  breast"1  (Figs.  40  and 


Fro.  41.— Funnel  Breast. 

41).  The  sides  of  the  chest  are  compressed  laterally  and  slope  in 
to  meet  the  sternum  as  the  sides  of  a  ship  slope  down  to  meet 
the  keel  ( pefftas  carinatum}  (Figs.  43  and  44).  From  the  origin 
of  the  ensiform  cartilage  a  depression  or  groove  is  to  be  seen  run- 
ning downward  and  outward  to  the  axilla  and  corresponding 
nearly  to  the  attachment  of  the  diaphragm.  This  is  sometimes 
spoken  of  as  "Harrison's  groove."  The  lower  inargin  of  the  ril* 

1  In  some  cases  this  condition  appears  to  be  congenital. 


INSPECTION.  63 

in  front  often  flares  out,  owing  to  the  enlargement  of  the  liver  and 
spleen  below  and  the  pull  of  the  diaphragm  above.  Along  the  line 
of  the  chondro-costal  articulation  there  is  to  be  felt,  and  sometimes 


FIG.  42.— Acquired  Depression  at  the  Root  of  the  Ensiform  Cartilage.  The  patient  is  a  shoe- 
maker of  seventy,  who  has  all  his  life  pressed  against  his  breast  bone  the  shoe  on  which  he 
worked. 

seen,  a  line  of  eminences  or  swellings,  to  which  the  name  of  "ra- 
chitic  rosary  "  has  been  given. 

(b)  The  "Paralytic  Thorax." 

Fig.  45  conveys  a  better  idea  of  this  form  of  chest  than  any 
description.  The  normal  anteroposterior  flattening  is  exaggerated 
so  that  such  persons  are  often  spoken  of  as  "flat-chested."  The 
clavicles  are  very  prominent,  owing  to  falling  in  of  the  tissues 


64  PHYSICAL  DIAGNOSIS. 

above  and  below  them;  the  shoulders  are  stooping,  the  scapulae 
prominent,  and  the  neck  is  generally  long.  The  angle  where  the 
ribs  meet  at  the  ensif  orm  cartilage,  the  so-called  "  costal  angle, "  is  in 
such  cases  very  sharp.  This  type  of  chest  has  often  been  supposed 
to  be  characteristic  of  phthisis,  but  may  be  found  in  persons  with 
perfectly  healthy  lungs.  On  the  other  hand,  phthisis  frequently 


FIG.  43.— Pigeon  Breast. 

exists  in  persons  with  normally  shaped  chests  or  with  abnormally 
deep  chests  (Woods  Hutchinson).      (See  Fig.  162,  page  310.) 

(c)  The  "Barrel  Chest," 

Nothing  is  less  like  a  barrel  than  the  "  barrel  chest. "  Its  most 
striking  characteristic  is  its  greatly  increased  anteroposterior  diam- 
eter, so  that  it  approaches  the  form  of  the  infant's  chest.  The 
costal  angle  is  very  obtuse,  the  shoulders  are  high,  and  the  neck 
is  short.  The  respiratory  movements  of  the  barrel  chest  will  be 
spoken  of  later  (see  Figs.  46  and  47). 


INSPECTIO^. 


65 


Nutrition  of  the  Chest  Walls. 

Emaciation  is  readily  appreciated  by  inspection.  The  ribs  are 
unusually  prominent,  the  scapulae  stand  out,  and  the  clavicles  pro- 
ject. All  this  may  be  seen  independently  of  any  change  in  the 


FIG.  44.— Pigeon  Breast. 

shape  of  the  chest  such  as  was  described  above  under  the  title  of 
Paralytic  Thorax.     Tuberculosis  of  the  apices  of  the  lungs  may 
produce  a  marked  falling  in  of  the  tissues  above  and  below  the 
clavicle  independent  of  any  emaciation  of  the  chest  itself. 
5 


66  PHYSICAL  DIAGNOSIS. 


III.  DEFORMITIES. 

The  abnormalities  just  enumerated  are  symmetrical  and  affect 
the  whole  thorax.  Under  the  head  of  Deformities,  1  shall  consider 
chiefly  such  abnormalities  as  affect  particular  portions  of  the  chest 
and  not  the  thorax  as  a  whole. 


(a)  Spinal  Curvatures  and  Twists.1 

A  good  view  of  the  patient's  back  brings  out  best  the  lesser  de- 
grees of  lateral  curvature,  which  are  not  at  all  infrequent  in  persons 
who  are  not  aware  of  them.  Slight  degrees  of  deformity  are  best 
seen  by  marking  with  a  skin-pencil  the  position  of  the  spinous  proc- 
esses (see  Fig.  49).  The  more  marked  cases  of  lateral  curvature, 
which  are  usually  accompanied  by  a  certain  amount  of  ticistiny, 
give  rise  to  considerable  displacement  of  the  thoracic  organs  and 
render  unreliable  the  usual  bony  landmarks,  with  reference  to 
which  we  judge  of  the  position  of  the  intrathoracic  organs.  By 
such  deformities  the  apex  of  the  heart  may  be  pushed  up  into 
the  fourth  space  or  out  into  the  axilla,  or  portions  of  the  lungs 
may  be  compressed  and  made  atelectatic.  The  bulging  on  the 
convex  side  of  the  curve  may  simulate  an  aneurismal  tumor. 
Pott's  disease  of  the  spine  should  be  looked  for  as  a  part  of 
the  routine  inspection  of  the  chest.  It  is  sometimes  better  felt 
than  seen. 

(i)  Flattening  of  One  Side  of  the  Chest. 

In  chronic  phthisis,  cirrhosis  of  the  lung,  or  long-standing  pleu- 
ritic effusion,  marked  falling  in  of  one  side  of  the  chest  is  often  to 
be  seen.  This  may  be  apparent  in  the  upper  and  front  portion,  be- 

1  See  also  page  54.  The  lesions  are  referred  to  here  only  in  relation  to 
their  effects  on  heart  and  lungs. 


INSPECTION. 


67 


neatli  the  clavicle,  or  in  the  axilla,  or  in  both  situations  (see  Figs. 
45  and  51).     The  shrinkage  of  the  affected  side  is  made  more  obvi- 


FIG.  45.— The  Paralytic  Thorax. 


ous  by  contrast  with  the  compensatory  hypertrophy  of  the  sound 
lung,  which  makes  the  sound  side  unusually  full  and  prominent. 


(c)  Prominence  of  One  Side  of  the  Chest. 

In  pneumothorax  or  pleural  effusions,  and  sometimes  in  malig- 
nant disease  of  the  lung  or  pleura,  there  is  a  marked  increase  in  the 
size  of  the  affected  side  of  the  chest.  Very  rarely  emphysema 


68 


PHYSICAL  DIAGNOSIS 


may  affect  one  lung  predominantly.     In  pneumothorax  or  pleuritic 

effusion  we  usually  see,  in  addition  to  the  above  enlargement  of  the 

affected  side,  a  smoothing  out  of 

the  intercostal  depressions  so  that 

the  surface  of  that  side  is  much 

more  uniform  than  the  other  side. 

Bulging  of  the  interspaces  from 

great   pressure   within    the  chest 

rarely  occurs.     I  have  never  seen 

it. 

(rf)  Local  Prominences. 

In  nearly  one-quarter  of  all 
healthy  chests  that  part  of  the 
thoracic  wall  which  overlies  the 
heart  (the  so-called  "precordial 
region")  is  abnormally  promi- 
nent.  The  cause  of  this  condi- 
tion is  much  disputed.  A  similar 
prominence  may  be  brought  about 
in  children,  whose  thoracic  bones 
are  very  flexible  (and  occasionally 
in  older  patients),  by  the  outward 
pressure  of  an  enlarged  heart  or 
of  an  effusion  in  the  pericardial 
sac.  The  prominences  due  to 
spinal  curvature  have  been  al- 
ready mentioned.  Less  com- 
mon  causes  of  local  prominence 
are: 

1.  Aneurism  of  the  arch    of 
the  aorta. 

2.  Tumor  of  the  chest  wall 

(lipoma,  sarcoma,  gumma)  or  of  the  lung,  mediastinum,  or  of  the 
thoracic  glands  pressing  their  way  outward. 


FIG.  46.  —Barrel  Chest  in  a  Case  of  Bron- 
chial  Asthma  (aet.  13). 


INSPECTION. 


69 


3.  "  Cold  abscess  "  (tuberculosis)  of  a  rib  or  of  the  sternum. 

4.  Empyema  perforating  the  chest  wall,  the  so-called  "empyema 
necessitatis. " 

IV.  THE  RESPIRATORY  MOVEMENTS. 

(a)  Normal  Respiration. 

During  normal  respiration,  one  sees  the  ribs  move  outward  and 
upward  with  inspiration,  and  downward  and  inward  with  expira- 
tion. Possibly  one  catches  some 
hint  of  the  movements  of  the 
diaphragm  at  the  epigastrium. 
In  men,  diaphragmatic  breath- 
ing is  more  marked,  while  in 
women  breathing  is  mostly  of 
the  "  costal  type  " ;  that  is,  is 
done  by  the  intercostal  muscles. 
In  certain  diseases  an  exaggera- 
tion of  the  costal  or  of  the  dia- 
phragmatic type  of  breathing 
may  be  seen.  In  emphysema, 
for  example,  and  in  some  cases 
of  asthma,  the  ribs  move  very 
little,  and  most  of  the  work  of 
respiration  is  performed  by  the 
diaphragm,  whose  pull  upon  the 
lower  ribs  can  sometimes  be  distinctly  seen  during  inspiration.  On 
the  other  hand,  when  the  movements  of  the  diaphragm  are  impeded 
by  the  presence  of  fluid  or  a  solid  tumor,  as  in  cirrhosis  of  the 
liver  or  leukaemia,  the  breathing  has  largely  to  be  performed  by  the 
ribs,  and  becomes,  as  we  say,  costal  in  type  (see  below,  p.  72). 


FIG.  47.— Barrel    Chest.    Chronic  bronchitis 
and  emphysema. 


(b)  Anomalies  of  Expansion. 

If  we  watch  the  patient  while  he  takes  a  full  breath,  we  may 
notice  certain  variations  from  the  normal  type  of  respiratory  move- 


70 


PHYSICAL  DIAGNOSIS 


meats.     We  may  see:   (1)  Diminished  expansion  of  one  side  (as  a 
whole,  or  at  the  apex).      (2)  Increased  expansion  of  one  side. 

(1)  If  diminished  expansion  of  one  side  is  due  to  pleuritic  effusion, 
pneumothorax,  or  solid  tumor  of  the  lung  or  pleura,  the  affected 
side  is  usually  distended  as  well  as  immobile.  When,  on  the  other 


Fio.  18.— Lateral  Curvature  Before  Cor- 
rection. 


FIG.   49.— Laternl  Curvnture  Three  Weeks 
After  Correction. 


hand,  the  lung  is  retracted  or  bound  down  by  adhesions,  as  in 
phthisis,  old  pleurisy,  occlusion  of  the  bronchus,  or  from  the  pres- 
sure of  an  aneurism,  we  have  immobiliity  combined  with  a  rHrm-t'inn 
of  the  affected  side.  In  tuberculous  disease  at  the  apex  of  the 
lungs  we  may  see.  one  side  or  both  sides  fail  to  expand  at  the  top. 
Restriction  of  the  motion  of  one  side  of  the  chest  may  also  be  due 
to  pain  or  to  pressure  from  below  the  diaphragm.  An  enlarged  liver 


INSPECTION. 


71 


or  spleen  and  tumors  of  the  hepatic  or  splenic  region  may  in  this  way 
prevent  the  normal  expansion  of  one  or  the  other  side  of  the  thorax. 

Occasionally  a  hemiplegia  or  a 
unilateral  paralysis  of  the 
diaphragm  results  in  dimin- 
ished movement  of  one  side  of 
the  chest. 

(2)  Increased  expansion  of 
one  side  of  the  chest  is  observed 
principally  as  a  compensatory 
or  vicarious  overf  unction  ing  of 
that  side  when  the  other  side 
of  the  chest  is  thrown  out  of 
use  by  a  large  pleuritic  effusion, 
by  pneumothorax,  long-stand- 
ing pleurisy  with  contraction, 
or  other  causes. 

(c)  Dyspnoea. 

This  term  is  often  used 
rather  loosely  to  include:  (1) 
Difficult  breathing,  whether 
rapid  or  slow.  (2)  Unusually 
deep  breathing,  whether  diffi- 
cult or  not.  (3)  Kapid  breath- 
ing. 

True    dyspnoea,   or   difficult 

is  almost  always  rapid  as  Avell,  and  does  not  differ  at  all 
from  the  well-known  phenomenon  of  being  "out  of  breath"  after  a 
hard  run  or  any  violent  exertion.  Conceive  these  conditions  as  per- 
sisting over  hours  or  days,  and  we  have  the  phenomenon  known  as 
dyspnoea.  The  breathing  is  not  only  quick  but  labored;  that  is, 
performed  with  difficulty,  and  unusual  muscles,  not  ordinarily  called 
upon  for  respiration,  come  into  play  and  are  seen  working  above 
the  clavicle  and  elsewhere.  More  or  less  distress  is  generally  ex- 
pressed in  the  face,  and  there  is  often  a  blueness  of  the  lips  or  a 
dusky  color  throughout  the  face.  The  commonest  causes  of  dysp- 


FIG.  50.  —Severe  Lateral  Curvature  (Un- 
treated). 


* 


72 


PHYSICAL  DIAGNOSIS. 


noea  are  the  various  forms  of  heart  disease,  pneumonia,  large 
pleuritic  effusion,  emphysema,  asthma,  and  phthisis. 

Dyspnoea  may  affect  especially  inspiration,  as,  for  example, 
when  a  foreign  body  lodges  in  the  larynx,  or  in  ordinary  "croup." 
In  such  cases  we  speak  of  "inspiratory  dyspnoea,"  distinguishing  it 
from  "  expiratory  dyspnoea  "  such  as  occurs  in  asthma  and  emphy- 
sema. In  the  latter  condition  the  breath  seems  to  enter  the  chest 
readily,  but  the  difficulty  is  to  get  it  out  again.  Expiration  is 
greatly  prolonged  and  often  noisy. 

Combined  types  also  occur  in  which  both  respiratory  acts  are 
difficult. 

Abnormally  deep  and  full  respiration,  without  any  appearance  of 
difficulty  in  the  process,  is  sometimes  seen  near  the  fatal  termina- 
tion of  cases  of  diabetes, 
the  so  -  called  diabetic 
dyspnoea. 

Simple  rapidity  of 
breathing  should  be  dis- 
tinguished from  dyspnosa 
of  any  type.  In  adults 
the  normal  rate  of  respi- 
ration is  about  18  per 
minute.  In  children,  it  is 
considerably  quicker  and 
more  irregular.  It  is  not 
desirable  to  attempt  here 
to  enumerate  all  the 
causes  which  may  lead  to 
a  quickening  of  the  respi- 
ration. Among  the  com- 
moner are  muscular  exer-  FIG.  5L-Contraction  of  Left  Chest.  Empyema. 
tion,  emotion,  hysteria, 

diseases  of  the  heart  and  lungs,  and  fluid  or  solid  accumulations 
below  the  diaphragm,  which  push  up  that  muscle  and  cause  it 
to  encroach  abnormally  upon  the  thoracic,  cavity.  Most  of  the  in- 
fectious fevers  are  also  apt  to  be  accompanied  by  quickened  breath- 


INSPECTION. 


73 


ing,  especially  but  not  exclusively  when  the  fever  is  associated  with 
a  disease  of  the  heart,  lung,  pleura,  or  pericardium. 

Sucking-in  of  the  interspaces  in  the  lower  axillary  regions  or 

below  the  clavicles  may 
be  seen  in  connection 
with  dyspnoea  when- 
ever the  lungs  are  pre- 
/  vented  by  some  cause 
from  properly  expand- 
ing during  inspiration. 
Negative  pressure  i  s 
thus  produced  within 
the  chest,  and  the  at- 
mospheric pressure 
without  pushes  in  the 
more  elastic  parts  of 
the  thorax.  This  phe- 
nomenon is  seen  in  col- 
lapse or  atelectasis  of 
a  portion  or  the  whole 
of  a  lung,  such  as  may 
occur  in  obstruction  at 
the  glottis  (in  which 
case  both  sides  are 
equally  retracted)  o  r 
from  occlusion  of  a 
bronchus.  In  the  lat- 
ter event,  the  sucking-in  of  the  interspaces  during  inspiration  oc- 
curs only  on  the  affected  side.1 

1  Slight  retraction  of  the  lower  interspaces  in  the  axilla  during  inspiration 
is  often  seen  in  health.     In  disease  this  phenomenon  is  greatly  exaggerated. 


FIG.  52.— Prominence  of  Right  Side.    Pleural  Effusion. 


74  PHYSICAL  DIAGNOSIS. 

* 

V.  CHANGES  IN  THE  RESPIRATORY  RHYTHM. 

(a)  Asthmatic  Breathing. 

In  asthma  the  normal  rhythm  is  reversed;  audible  expiration 
becomes  longer,  instead  of  shorter,  than  inspiration.  Inspiration 
may  be  represented  only  by  a  short  gasp,  while  expiration  becomes 
a  prolonged  wheeze  lasting  several  times  as  long  as  inspiration. 
Dyspnoea  is  usually  very  marked.  In  emphysema  we  get  very 
much  the  same  type  of  breathing  so  far  as  rhythm  is  concerned, 
but  the  dyspnoea  is  not  usually  so  extreme  and  the  auxiliary  mus- 
cles of  respiration  are  not  so  apt  to  be  called  into  use.  In  many 
cases  of  emphysema  one  sees  the  thorax  move  all  as  one  piece,  "  en 
cuirasse,"  owing  to  a  senile  fixation  of  the  bones  of  the  thorax  from 
ossification  of  the  cartilaginous  portions.  In  hereditary  syphilis  or 
phthisis  this  fixation  may  occur  in  youth  or  early  middle  age. 

(b)  C hey ne- Stokes  Breathing. 

An  anomaly  of  respiratory  rhythm  in  which  short,  recurrent 
paroxysms  of  dyspnoea  are  preceded  and  followed  by  periods  in 
which  no  respiration  occurs  (apnoea).  If  we  represent  the  normal 
respiratory  movement  by  an  up-and-down  line,  as  seen  in  Fig.  53, 

VWWAVW 

FIG.  53.— Diagram  to  Represent  Normal  Breathing-Rhythm. 

• 

the  Cheyne-Stokes  type  of  breathing  would  appear  as  in  Fig.  54. 
The  period  of  apncea  may  last  from  one  to  ten  seconds ;  then  short, 
shallow  respirations  begin  and  increase  rapidly,  both  in  volume  and 
in  rate,  until  a  maximum  of  marked  dyspnoea  is  reached,  when  a 
diminution  in  the  rate  and  depth  of  the  act  begins,  and  the  patient 
gradually  returns  to  the  apnoeic  state.  The  length  of  the  whole 
paroxysm  may  be  from  30  to  70  seconds.  During  the  apnceic 
period  the  patient  is  apt  to  drop  asleep  for  a  few  seconds  and  the 
pupils  may  become  contracted.  When  the  paroxysm  of  dyspnoea 


INSPECTION.  75 

is  at  its  height,  he  is  apt  to  cough  and  shift  his  position  restlessly, 
or  in  case  the  whole  phenomenon  occurs  during  sleep  he  moves  un- 
easily in  his  sleep  at  this  period.  Modified  types  of  the  phenome- 
non also  occur,  in  which  there  is  a  rhythmic  increase  and  decrease 
in  the  depth  and  rapidity  of  respiration  but  without  any  interven- 
ing period  of  apnoea.  This  type  of  breathing  is  most  often  seen  in 
severe  cases  of  cardiac,  renal,  or  cerebral  disease.  It  is  generally 
more  marked  at  night  and  may  occur  only  at"  that  time.  In  chil- 
dren it  appears  sometimes  to  be  physiological  during  sleep.  As  a 


FIG.  54.— Cheyne-Stokes  Respiration. 

rule,  it  is  a  sign  of  grave  prognostic  significance,  but  patients  have 
been  known  to  recover  completely  after  weeks  or  even  months  of 
Cheyne-Stokes  breathing. 

(c)  Restrained  or  "  Catchy  "  Breathing. 

When  the  patient  has  a  "stitch  in  the  side,"  due  to  dry  pleu- 
risy, intercostal  neuralgia,  or  to  other  causes,  the  inspiration  may 
be  suddenly  interrupted  in  the  middle,  owing  to  a  seizure  of  pain 
which  makes  the  patient  stop  breathing  as  quickly  as  he  can.  The 
same  conditions  may  produce  very  shallow  breathing  as  the  patient 
tries  to  avoid  the  pain  which  a  fall  inspiration  will  cause.  This 
type  of  restrained  breathing  is  often  seen  in  pleurisy  and  pneumo- 
nia, and  in  the  latter  disease  expiration  is  often  accompanied  by 
a  little  moan  or  grunt  of  discomfort 

(cT)  Shallow  and  irregular  breathing  is  often  seen  in  states  of  pro- 
found unconsciousness  from  any  cause,  such  as  apoplexy  or  poisou.- 
ing.  A  few  deep  respirations  may  be  followed  by  a  number  of 
shallow  and  irregular  ones. 

(«)  Stemo-mastoid  breathing.  When  death  is  imminent  in  any 
disease,  the  respiration  may  become  very  irregular  and  gasping,  and 
it  is  apt  to  be  accompanied  by  a  peculiar  nodding  movement  of  the 


76  PHYSICAL  DIAGNOSIS. 

head,  the  chin  being  thrown  quickly  upward  during  inspiration,  and 
falling  slowly  during  expiration.  I  have  known  but  one  patient  to 
recover  after  this  type  of  breathing  had  set  in. 

After  severe  hemorrhage  the  breathing  may  be  of  a  sighing  type 
as  well  as  very  shallow. 

(e)  Stridulous  Breathing. 

A  high-pitched,  crowing  or  barking  sound  is  heard  during  inspi- 
ration when  there  is  obstruction  of  the  entrance  of  air  at  or  near 
the  glottis.  This  type  of  breathing  occurs  in  spasm  or  oedema  of 
the  glottis,  "croup,"  laryngismus  stridulus,  and  forms  the  "whoop  " 
in  the  paroxysms  of  whooping-cough.  Laryngeal  or  tracheal  ob- 
structions due  to  foreign  bodies,  or  tumors  within  or  pressure  from 
without  the  air-tubes,  may  cause  a  similar  type  of  respiration.  It 
is  in  these  cases  especially  that  we  see  the  sucking-in  of  the  inter- 
spaces mentioned  above  (see  p.  73). 

VI.  DIAPHRAGMATIC  MOVEMENTS. 

The.  Phrenic  Wave. 

The  normal  movements  of  the  diaphragm  may  be  rendered  vis- 
ible by  the  following  procedure,  suggested  by  Litten  in  1892 :  The 
patient  lies  upon  his  back  with  the  chest  bared  and  the  feet  pointed 
directly  toward  a  window.  Cross  lights  must  be  altogether  ex- 
cluded by  darkening  any  other  windows  which  the  room  may  con- 
tain1 (see  Fig.  55).  The  observer  stands  at  the  patient's  side 
and  asks  him  to  take  a  full  breath.  As  the  ribs  rise  with  the 
movement  of  inspiration,  a  short,  narrow  shadow  moves  down  along 
the  axilla  from  about  the  seventh  to  about  the  ninth  or  tenth  rib. 
During  the  expiration  the  shadow  rises  again  to  the  point  from 
which  it  started,  but  is  less  easily  seen.  This  phenomenon  is  to  be 
seen  on  both  sides  of  the  chest  and  sometimes  in  the  epigastrium. 

1  If  it  is  inconvenient  to  move  the  patient's  bed  into  the  proper  position 
with  relation  to  the  window  or  if  the  foot-board  interferes,  or  if  the  observa- 
tion has  to  be  made  after  dark,  a  dark  lantern  or  other  strong  light  held  at  the 
foot  of  the  bed  answers  very  well.  All  other  light  must,  of  course,  be  ex- 
cluded. 


INSPECTION. 


77 


It  is  best  seen  in  spare,  muscular  young  persons  of  either  sex,  and 
is  never  absent  in  health  except  in  those  who  are  very  fat,  or  who 
cannot  or  will  not  breathe  deeply.  The  latter  condition  occurs  in 


FIG,  55.— Litten's  Diaphragm  Shadow.    Proper   position  of   patient  and   of   observer.    The 
shadow  is  best  seen  near  L. 

hysteria  and  in  some  very  stupid  persons  who  cannot  be  made  to 
understand  what  is  meant  by  a  full  breath.  In  the  observation  of 
several  thousand  cases,  I  have  never  known  it  absent  in  health 
except  under  these  conditions. 

In  normal  chests,  the  excursion  of  the  shadow  is  about  two  and 
a  half  inches;  with  very  forced  breathing  three  and  a  half  inches. 
The  mechanism  of  this  phenomenon  is  best  understood  by  imagin- 
ing a  coronal  section  of  the  thorax  as  seen  from  the  front  or  back 
(see  Fig.  56).  At  the  end  of  expiration,  the  diaphragm  lies 
flat  against  the  thorax  from  its  attachment  up  to  about  the  sixth 
rib.  During  inspiration  it  "peels  off"  as  it  descends  and  allows 
the  edge  of  the  lung  to  come  down  into  the  chink  between  the  dia- 
phragm and  thorax.  This  "peeling  off"  of  the  diaphragm  and  the 
descent  of  the  lung  during  inspiration  give  rise  to  the  moving 
shadow  above  described. 

By  thus  observing  the  excursion  of  the  diaphragm  we  can  obtain 
a  good  deal  of  information  of  clinical  value. 


78 


PHYSICAL  DIAGNOSIS. 


In  pneumonia  of  the  lower  lobe,  pleuritic  effusion,  extensive  pleu- 
ritic adhesions,  or  in  advanced  cases  of  emphysema,  the  shadow  is 
absent.  This  is  explained  by  the  fact  that  in  pneumonia,  pleuritic 
effusion,  and  emphysema  the  diaphragm  is  held  off  from  the  chest 
wall  so  that  its  movements  communicate  no  shadow.  In  pleuritic 
adhesions  the  movements  of  the  diaphragm  are  prevented.  In 
early  phthisis  I  have  generally  found  the  excursion  of  the  dia- 
phragm diminished  upon  the  affected  side,  owing  to  a  loss  of 
elasticity  in  the  affected  lung  and  in  part  probably  to  pleuritic 
adhesions.  On  the  other  hand,  fluid  or  solid  tumors  below  the  dia- 
phragm, unless  very  large,  do  not  prevent  the  descent  of  that  muscle, 
and  so  do  not  abolish  the  diaphragm  shadow.  In  cases  in  which 
the  diagnosis  is  in  doubt  between  fluid  in  the  right  pleural  cavity 
and  an  enlargement  of  the  liver  upward  or  a  subdiaphraguiatic  ab- 
seess,  the  preservation  of  the  Litten's  phenomenon  in  the  latter  two 
affections  may  be  of  great  value  in  diagnosis.  Very  large  accumu- 
lations of  ascitic  fluid  may  so  far  restrain  the  diaphragmatic  move- 
ments that  no  shadow  can  be  seen.  Great  muscular  weakness  or 
debility  may  greatly  diminish,  but  rarely  if  ever-  prevent,  the  excur- 


FIG.  56.— Excursion  of  the  Diaphragm  during  Forced  Respiration.     R,  Ribs ;    B,  position  of 
tbe  diaphragm  at  end  of  expiration ;  7,  position  of  diaphragm  at  end  of  Inspiration. 

sion  of  the  shadow.  In  persons  who  cannot  be  made  to  breathe 
deeply  enough  to  bring  it  out,  a  hard  cough  will  frequently  render 
it  visible. 

The  use  of  this  method  of  examination  tends,  to  a  certain  ex- 
tent, to  free  us  from  the  necessity  of  using  the  arrays,  inasmuch  as 


INSPECTION.  79 

it  furnishes  us  with  the  means  of  observing  the  diaphragmatic 
movements,  on  the  importance  of  which  so  much  stress  has  been 
laid  by  F.  H.  Williams  and  others,  much  more  easily  and  cheaply 
than  with  the  ic-rays,  and  upon  the  left  side,  more  plainly  as  well. 

It  also  frees  us  to  a  considerable  extent  from  the  need  of  using 
the  spirometer  to  determine  the  capacity  of  the  lungs. 

By  measuring  the  excursion  of  the  phrenic  shadow  and  taking 
account  of  the  thoracic  movement,  we  obtain  a  very  fair  idea  of  the 
respiratory  capacity  of  the  individual. 

VII.  OBSERVATION  OF  THE  CARDIAC  MOVEMENTS. 
(1)  The  Normal  Cardiac  Impulse. 

With  each  systole  of  the  heart  there  may  be  seen  in  the  great 
majority  of  normal  chests  an  outward  movement  of  a  small  portion 
of  the  chest  wall  just  inside  and  below  the  left  nipple.  This  phe- 
nomenon is  known  as  the  cardiac  impulse.1  It  is  now  generally 
admitted  that  the  "apex  impulse  "is  caused  by  the  impact  of  a 
portion  of  the  right  ventricle  against  the  chest  wall  and  not  by  the 
apex  of  the  heart  itself.  [The  bearings  of  this  fact,  which  have 
not,  I  think,  been  generally  appreciated,  will  be  discussed  pres- 
ently.] The  position  of  the  maximum  impulse  in  adults  is  usually 
in  the  fifth  intercostal  space  just  inside  the  nipple  line.  In  chil- 
dren under  the  age  of  six  it  is  often  in  the  fourth  interspace  or 
behind  the  fifth  rib;  while  in  persons  of  advanced  age  it  often  de- 
scends as  low  as  the  sixth  interspace.  In  adults  it  is  occasionally 
absent  even  in  perfect  health  and  under  certain  pathological  condi- 
tions to  be  later  mentioned. 

(a)  The  position  of  the  impulse  varies  to  a  certain  extent  ac- 
cording to  the  position  of  the  body.  If  the  patient  lies  upon  the 
left  side,  the  heart's  apex  swings  out  toward  the  axilla,  so  that 
the  visible  impulse  shifts  from  one  to  two  and  one-half  inches  to 
the  left  (see  Fig.  57).  A  slight  shift  to  the  right  can  also  be 
brought  about  by  lying  upon  the  right  side,  and,  as  a  rule,  the  im- 
pulse is  less  visible  in  the  recumbent  than  in  the  upright  position. 

1  For  a  more  detailed  description  of  the  normal  position  of  the  cardiac 
impulse,  see  next  page. 


80 


PHYSICAL  DIAGNOSIS. 


Since  the  heart  is  lifted  with  each  expiration  by  the  rise  of  the  dia- 
phragm, and  falls  during  inspiration,  a  corresponding  change  can  be 
observed  in  the  apex  beat,  which,  in  forced  breathing,  may  shift  as 
much  as  one  interspace.  Of  the  changes  in  the  position  of  the  im- 
pulse brought  about  by  disease,  I  shall  speak  in  a  later  paragraph. 


FIG.  57.— Showing  Amount  of  Shifting  of  the  Apex  Impulse  with  Change  of  Position.  The  in 
ner  dot  represents  the  position  of  the  impulse  when  the  patient  lies  on  bis  back ;  the  outei 
dot  corresponds  to  the  position  of  the  apex  with  patient  on  left  side. 

(&)  Relation  of  the  maximum  cardiac  impulse  to  the  apex  of  the 
heart. — I  mentioned  above  that  the  maximum  cardiac  impulse  is  not 
due  to  the  striking  of  the  apex  of  the  heart  against  the  chest  wall, 
but  to  the  impact  of  a  portion  of  the  right  ventricle.  The  practical 
importance  of  this  fact  is  this:  When  we  are  trying  to  localize  the 
apex  of  the  heart  in  order  to  determine  how  far  the  organ  extends 
to  the  left  and  downward,  it  will  not  do  to  be  glided  by  the  posi 


INSPECTION. 


81 


tion  of  the  maximum  impulse, .for  the  apex  of  the  heart  is  almost 
always  to  be  found  three -fourths  of  an  inch  or  more  farther  to  the 
left  (see  Fig.  58) .  This  may  be  proved  by  percussion  (vide  infra, 


FIG.  58.— The  Inner  Dot  Is  the  Maximum  Cardiac  Impulse.    That  to  the  right  is  the  true  apex 
of  the  heart,  as  obtained  by  percussion.    The  ribs  are  numbered. 

p.  58).  The  true  position  of  the  cardiac  apex  thus  determined  cor- 
responds usually  not  with  the  maximum  impulse,  but  with  the  point 
farthest  out  and  farthest  down  at  which  any  rise  and  fall  syn- 
chronous with  the  heart  beat  can  be  felt  (for  further  discussion  of 
this  point  see  below,  p.  272). 

(c)   Besides  the  definite  and  localized  impulse  which  has  just 

been  described,  it  is  often  possible  to  see  that  a  considerable  section 

of  the  chest  wall  in  the  precordial  region  is  lifted  "en  masse." 

The  phenomenon  is  the  "  Herzenstoss  "  of  the  Germans,  with  which 

6 


82  PHYSICAL  DIAGNOSIS. 

the  "  Spitzenstoss "  or  apex  impulse  is  contrasted.  A  variable 
amount  of  "  Herzenstoss "  can  be  seen  arid  felt  over  any  normal 
heart  when  it  is  acting  rapidly  and  forcibly,  and  in  thin,  nervous 
subjects  or  in  children  even  when  the  heart  is  beating  quietly.  It 
is  more  marked  in  cardiac  neuroses  or  in  cases  in  which  the  heart 
is  hypertrophied  and  in  which  there  is  more  or  less  stiffening  of  the 
ribs  with  loss  of  their  natural  elasticity.  At  times  it  may  be 
impossible  to  localize  any  one  point  to  which  we  can  give  the 
name  of  apex  impulse,  and  what  we  see  is  the  rhythmical  rise  and 
fall  of  a  section  of  the  chest  as  large  as  the  palm  of  the  hand  or 
larger. 

(<Z)  Character  of  the  cardiac  impulse. — Palpation  is  considerably 
more  effective  than  inspection  in  giving  us  information  as  to  the  na- 
ture of  the  cardiac  movements  which  give  rise  to  the  "apex  beat," 
but  even  inspection  sometimes  suffices  to  show  that  the  impulse  has 
a  heaving  character  or  is  of  the  nature  of  a  short  tap,  a  peristaltic 
wave,  or  a  diffuse  slap  against  the  chest  wall.  In  some  cases  a  dis- 
tinct undulation  can  be  seen  passing  from  the  apex  region  upward 
toward  the  base  of  the  heart,  or  less  often  in  the  opposite  direction. 

(2.)  Displacement  of  the  Cardiac  Impulse. 

To  one  familiar  with  the  position,  extent,  and  character  of  the 
normal  cardiac  impulse,  any  displacement  of  this  impulse  from  its 
normal  site  or  any  superadded  pulsation  in  another  part  of  the  chest 
is  apparent  at  a  glance.  I  will  consider  first  the  commonest  forms 
of  dislocation  of  the  apex  impulse. 

(a)  Displacement  of  the  cardiac  impulse  due  to  hypertrophy  and 
dilatation  of  the  heart. — By  far  the  most  common  directions  of  dis- 
placement are  toward  the  left  axilla,  or  downward.  As  a  rule,  it 
is  displaced  in  both  these  directions  at  once.  I  shall  return  to  this 
subject  more  in  detail  under  the  heading  Cardiac  Hypertrophy,  but 
here  I  may  say  that  enlargements  of  the  left  ventricle  tend  espe- 
cially to  displace  the  apex  impulse  downward,  while  enlargements  of 
the  right  ventricle  are  more  commonly  associated  with  displacement 
of  the  impulse  toward  the  axilla. 

(ft)  Next  to  hypertrophy  and  dilatation  of  the  heart  perhaps  the 
commonest  cause  of  dislocation  of  the  cardiac  impulse  is  pressure 


INSPECTION.  83 

from  below  the  diaphragm.  When  the  diaphragm  is  raised  by  a 
large  accumulation  of  gas  or  fluid  or  by  solid  tumors  of  large  size, 
we  may  see  the  apex  beat  in  the  fourth  interspace  and  often  an  inch 
or  more  inside  the  nipule  line. 

(c)  Of  nearly  equal  frequency  is  displacement  of  the  heart  due 
to  pleuritic  effusion  or  to  pneumothorax  (see  below,  p.  336). 

When  a  considerable  amount  of  air  or  fluid  accumulates  in  the 
left  pleural  cavity,  the  heart  bodily  is  displaced  to  the  right  so  that 
it  may  be  concealed  behind  the  sternum  or  be  visible  beyond  it  to 
the  right;  in  extreme  cases  it  may  be  dislocated  as  far  as  the  right 
nipple.  Eight  pleuritic  effusions  have  far  less  effect  upon  the  posi- 
tion of  the  cardiac  impulse,  but  when  a  very  large  amount  of  fluid 
accumulates  we  may  see  the  impulse  displaced  considerably  toward 
the  left  axilla. 

(d)  I  have  mentioned  causes  tending  to  push  the  heart  to  the 
right,   to  the  left,   or  upward.     Occasionally  the  heart  is  pushed 
downward  by  an  aneurismal  tumor  or  a  neoplasm  of  the  mediasti- 
num.    In  these  cases  there  is  usually  more  or  less  displacement  to 
the  left  as  well.     As  a  result  of  arteriosclerosis  or  cardiac  hyper- 
trophy the  aorta  may  sag  or  stretch  a  little,  and  the  diaphragm 
stands  lower,  and  hence  the  apex  beat  may  descend  to  the  sixth  in- 
terspace, or  (more  often)  it  may  be  lost  to  sight  and  touch  behind 
the  bunch  of  convergent  costal  cartilages  just  to  the  left  of  the 
ensiform.     Very  frequently  in  men  past  forty-five  the  whole  heart 
sinks  considerably,  so  that  a  marked  systolic  retraction  (less  often 
pulsation)  is  seen  below  the  ensiform  in  the  epigastrium. 

(e)  Displacement  of  the  cardiac  impulse  resulting  from  adhesions 
of  the  pericardium,  or  of  the  pleura,  with  subsequent  contraction, 
occurs  in  fibroid  phthisis  and  in  some  cases  of  long-standing  disease 
of  the  pleura.     Through  the  effect  of  negative  pressure  the  heart 
may  be  sucked  into  the  space  formerly  occupied  by  a  portion  of  the 
lung,  when  the  latter  has  become  contracted  by  disease.     It  seems 
likely,  however,  that  in  the  majority  of  cases  adhesions  between 
the  pleura  and  pericardium  play  a  part  in  such  displacement.     By 
these  means  the  heart  may  be  displaced  to  the  right  of  the  sternum, 
as  it  is  by  left-sided  pleuritic  effusion.     It  is  often  drawn  upward 


84  PHYSICAL  DIAGNOSIS. 

as  well  as  to  the  right  in  such  cases  by  the  contraction  which  takes 
place  in  the  upper  part  of  the  lung.  More  rarely  we  may  see  the 
heart  drawn  toward  the  left  clavicle  in  fibroid  phthisis  of  the  left 
apex. 

(/)  Distortion  of  the  thorax  due  to  spinal  curvature  or  other 
causes  may  bring  about  a  considerable  displacement  of  the  heart 
from  its  normal  position. 

(<7)  Dextrocardia  and  Situs  Inversus. — In  rare  cases  a  displace- 
ment of  the  apex  impulse  to  the  right  of  the  sternum  may  be  due 
either  to  a  transposition  of  all  viscera  [the  liver  being  found  upon 
the  left,  the  spleen  upon  the  right,  etc.],  or  to  dextrocardia,  in  which 
the  heart  alone  is  transposed  while  the  other  viscera  retain  their 
normal  places. 

Summary. 

The  apex  impulse  is  displaced  by 

(a)  Hypertrophy  and  dilatation  of  the  heart. 

(/>)  Pressure  from  below  the  diaphragm. 

(c)  Air  or  fluid  in  one  pleural  cavity,  especially  the  left. 

(cF)  Aneurism,  mediastinal  growths,  and  sagging  of  the  aorta. 

(e)  Fibroid  phthisis. 

(/)  Spinal  curvature. 

(^7)  Transposition  of  the  heart  or  of  all  the  viscera. 

(3)  Apex  Retraction. 

Before  leaving  the  subject  of  the  cardiac  impulse  it  seems  best 
to  speak  of  those  cases  in  which  during  systole  we  see  a  retraction 
of  one  or  more  interspaces  at  or  near  the  point  where  the  cardiac 
impulse  normally  appears. 

(a)  In  by  far  the  greater  number  of  instances  such  retraction  is 
due  to  negative  pressure  produced  within  the  chest  by  the  vigorous 
contraction  of  a  more  or  less  hypertrophied  and  dilated  heart.  In 
these  cases  the  retraction  is  usually  balanced  by  an  impulse  in  the 
next  interspace,  so  that  a  "  walking  beam "  appearance  is  the 
result. 

(£»)  In  rarer  cases  several  interspaces,  both  in    the  precordial 


INSPECTION.  85 

region  and  in  the  left  lower  axilla  and  back,  may  be  drawn  in  as  a 
result  of  adhesions  between  the  pericardium  and  the  chest  wall, 
such  as  form  in  cases  of  adherent  pericardium  and  fibrous  rnedias- 
tinitisj(see  below,  pages  276  and  303.) 

(4)  Epigastric  Pulsation. 

In  a  considerable  portion  of  healthy  adults  a  pulsation  or  retrac- 
tion at  the  epigastrium  synchronous  with  the  systole  of  the  heart  is 
to  be  seen  from  time  to  time.  Such  pulsation  has  often  been  treated 
as  evidence  of  hypertrophy  of  the  right  ventricle  of  the  heart,  but 
this  I  believe  to  be  an  error.  It  is  not  at  all  uncommon  to  find, 
post  mortem,  considerable  hypertrophy  of  the  right  ventricle  in  cases- 
in  which  during  life  no  epigastric  pulsation  has  been  visible,  while, 
on  the  other  hand,  the  heart  is  frequently  found  normal  at  autopsy 
in  cases  MI  which  during  life  there  has  been  marked  epigastric  pul- 
sation. In  some  cases  such  pulsation  is  to  be  explained  as  the 
transmission  of  the  heart's  impulse  through  the  liver,  or  as  a  lifting 
of  that  organ  by  the  movements  of  the  abdominal  aorta.  In  other 
cases  it  is  due  to  bathycardia  ("  low  heart  " — a  condition  very  com- 
mon in  arteriosclerosis). 

(5)    Visible  Pulsations  due  to   Uncovering  of  Portions  of  the  Heart 
Normally  Covered  by  the  Lungs. 

One  of  the  commonest  causes  of  visible  pulsations  in  parts  of 
the  chest  where  normally  none  is  to  be  seen  is  retraction  of  the 
lung. 

(a)  It  is  in  chlorosis,  perhaps,  that  we  most  frequently  see 
such  pulsations.  In  that  disease,  as  in  other  debilitated  states,  the 
lungs  are  often  not  adequately  expanded  owing  to  the  superficiality 
of  the  respiration,  and  accordingly  their  margins  do  not  cover  as 
much  of  the  surface  of  the  heart  as  they  do  in  healthy  adults. 
This  results  in  rendering  visible,  in  the  second,  third,  or  fourth  left 
interspace  near  the  sternum,  pulsations  transmitted  from  the  conus 
arteriosus  or  from  the  right  ventricle.  Less  commonly,  similar  pul- 
sations may  be  seen  on  the  right  side  of  the  sternum. 
•  l  Or  more  often  as  a  result  of  simple  cardiac  hypertrophy.  More  cases  of 
aortic  regurgitation  in  thin  young  patients  show  this  systolic  retraction  in  the 
left  lower  back. 


86 


PHYSICAL  DIAGNOSIS. 


(b)  A  rarer  cause  of  retraction  of  the  lungs  is  fibroid  phthisis 
or  chronic  interstitial  pneumonia.  In  these  diseases  a  very  large 
area  of  pulsation  may  be  seen  in  the  precordial  region  owing  to  the 
entire  uncovering  of  the  heart  by  the  retracted  lung,  even  when  the 
heart  is  not  drawn  out  of  its  normal  position. 

VIII.   ANEURISM  AND  OTHER   CAUSES    OF   ABNORMAL   THORACIC 

PULSATION. 

So  far  I  have  spoken  altogether  of  pulsations  transmitted  di- 
rectly to  the  thorax  by  the  heart  itself,  but  we  have  also  to  bear  in 


Position  When  Looking  for  Slight  Aneurismal  Pulsation. 


mind  that  a  dilated  aorta  may  transmit  to  the  chest  wall  pulsations 
which  it  is  exceedingly  important  for  us  to  recognize  and  properly  to 
interpret.  No  disease  is  easier  to  recognize  than  aneurism  when  the 
growth  has  perforated  the  chest  wall  and  appears  as  a  tumor  exter- 
nally, but  it  is  much  more  important  as  well  as  much  more  difficult 
to  recognize  the  disease  while  it  is  confined  within  the  thorax.  In 
such  cases,  the  movements  transmitted  from  the  aorta  to  the  chest 
wall  may  be  so  slight  that  only  the  keenest  and  most  thorough  in- 


INSPECTION.  87 

spection  controlled  by  palpation  will  detect  them.  When  slight 
pulsations  are  searched  for,  the  patient  should  be  put  in  a  position 
shown  in  Fig.  59,  and  the  observer  should  place  himself  so  that  his 
eye  is  as  nearly  as  possible  on  a  level  with  the  chest  and  looks 
across  it  so  that  he  sees  it  in  profile.  In  this  position,  or  in  a  sitting 
position  with  tangential  light,  he  can  make  out  pulsations  which  are 
totally  invisible  if  the  patient  sits  facing  the  light. 

Pulsations  due  to  aneurism  are  most  apt  to  be  seen  in  the  first 
or  second  right  interspace  near  the  sternum,  and  not  infrequently 
the  clavicle  and  the  adjacent  parts  may  be  seen  to  rise  slightly  with 
every  beat  of  the  heart,  but  in  any  part  of  the  chest  wall  pulsa- 
tions due  to  an  aneurism  are  occasionally  to  be  seen,  and  should  be 
looked  for  scrupulously  whenever  the  symptoms  of  the  case  suggest 
the  possibility  of  this  disease  (see  below,  p.  281). 

Pulsating  Pleurisy. 

In  cases  of  purulent  pleurisy  in  which  the  pus  has  worked  its 
way  out  betwen  the  ribs  so  that  it  is  covered  only  by  the  skin  and 
subcutaneous  tissues,  a  pulsation  transmitted  from  the  heart  may 
become  visible,  and  the  resemblance  to  the  pulsation  seen  in  aneu- 
rism may  be  confusing.  Such  pulsation  is  apt  to  be  seen  in  the 
upper  and  front  portions  of  the  chest.  Very  rarely  a  pleuritic  effu- 
sion which  has  not  burrowed  into  the  chest  wall  may  transmit  to 
the  latter  a  wavy  movement  corresponding  to  the  motions  set  up 
in  the  fluid  by  the  cardiac  contractions. 

IX.  INSPECTION  OF  THE  PERIPHERAL  VESSELS. 

In  the  study  of  all  diseases  of  the  heart  and  lungs  it  is  import- 
ant to  take  account  of  all  vascular  phenomena  apparent  in  the 
neck  or  in  the  extremities,  since  such  phenomena  have  a  very  direct 
bearing  upon  the  interpretation  of  the  conditions  obtaining  within 
the  chest.  Inspection  plays  a  very  large  part  in  the  study  of  these 
vascular  phenomena.  We  should  look  for:  (a)  Venous  phenomena  ; 
(b]  Arterial  phenomena;  (c)  Capillary  phenomena. 


88  PHYSICAL  DIAGNOSIS. 


(a)  Inspection  of  the  Veins. 

1.  The  condition  of  the  veins  of  the  neck  is  of  considerable  im- 
portance in  the  diagnosis  of  diseases  of  the  heart  and  lungs.    Where 
the  tissues  of  the  neck  are  more  or  less  wasted  the  veins  may  be 
quite  prominent  even  when  no  disease  exists  within  the  chest,  and 
in  such  cases  they  may  be  more  or  less  distended  during  each  expi- 
ration,  especially  if  dyspnoea  or  cough  is  present.     If  the  over- 
distended  veins  are  completely  emptied    during  deep  inspiration 
and  on  both  sides  of  the  neck,  we  can  usually  infer  that  there  is  an 
overdistention  of  the  right  side  of  the  heart.      When  a  similar 
phenomenon  occurs  on  one  side  only,  it  may  mean  pressure  upon 
one  innominate  vein.     So  far  I  have  spoken  of  venous  changes 
synchronous  with  respiration,  but  we  may  have  also 

2.  A  presystolic  pulsation  or  undulation  seen  either  in  the  ex- 
ternal jugular  vein  or  in  the  bulbus    jugularis    between  the  two 
attachments   of  the   stern omastoid   muscles.      Such    pulsation  or 
undulation,  which  is  to  be  seen    just   before  each  systole  of  the 
heart,  is  not  necessarily  anything  abnormal  and  must  be  carefully 
distinguished  from 

3.  Systolic  venous  pulsation,  such  as  occurs  in  one  of  the  most 
common  valvular  diseases  of  the  heart — tricuspid    regurgitation. ' 
Systolic  venous  pulsation  is  more  often  seen  upon  the  right  side 
than  upon  the  left  side  of  the  neck.     There  may  be  a  wave  during 
the  systole  of  the  auricle  and  another  during  the  systole  of  the  ven- 
tricle, the  latter  closely  following  the  former.     In  any  case  in 
which  a  doubt  arises  whether  a  pulsation  in  the  veins  of  the  neck 
is  due  to  tricuspid  regurgitation,  it  is  well  to  try  the  experiment  of 
emptying  the  vein  by  stroking  it  from  below  upward.     If  it  imme- 
diately fills  from  below,  we  may  be  practically  certain  that  tricus- 
pid regurgitation  is  present.     In  the  vast  majority  of  cases  of  ve- 
nous pulsation  due  to  other  causes  or  occurring  in  healthy  persons 

1  A  pulsating  carotid  may  transmit  an  up-and-down  motion  to  the  veins 
overlying  it.  In  such  cases,  if  the  veins  be  emptied  by  "milking"  them  up- 
ward, they  will  not  refill  from  below. 


INSPECTION. 


89 


a  vein  will  not  refill  from  below  it'  emptied  in  the  manner  above 
described. 

4.  Rarely,  superficial  veins  may  be  seen  to  pulsate  in  other  parts 
of  the  body,  especially  in  aortic  regurgitation,  and  occasionally 
large  and  tortuous  veins  may  be  seen  pulsating  upon  the  thoracic 


FIG.  60.— Tortuous  Veins  on  Chest  and  Abdomen.    (Autopsy  showed  obliteration  of  the  vem 

cava  inferior.) 

or  abdominal  wall,  representing  an  attempt  at  collateral  circulation 
Avhen  one  or  the  other  vena  cava  is  compressed  (Fig.  60). x 

(6)  Arterial  Phenomena. 

1.  In  thin  or  nervous  persons  pulsations  are  not  infrequently  to 
be  seen  in  the  carotids  independent  of  any  abnormal  condition  of 
the  heart. 

1  Enlarged  veins  about  the  navel,  the  so-called  "caput  Medusae,"  are  com- 
monly found  in  text-books,  but  rarely  in  cirrhosis  of  the  liver. 


90 


PHYSICAL  DIAGNOSIS. 


2.  Very  violent  throbbing  of  the  carotids,  more  noticeable  than 
the  normal,  occurs  in  severe  anaemias  in  many  cases  and  occasion- 
ally in  simple  hypertrophy  of  the  heart  without  any  valvular  dis- 
ease. From  the  same  causes,  visible  pulsation  may  occur  in  the 
subclavian,  axillary,  brachial,  and  radial  arteries,  as  well  as  in  the 
large  arterial  trunks  of  the  lower  extremity. 

I  lately  examined  a  blacksmith  whose  heart  was  considerably 
enlarged  by  hard  work,  but  without  any  valvular  disease.  Pulsa- 


FiG.  01.— Enlarged  Tortuous  Hracbial  Arteries  (Arterio-sclerosis). 

tion  was  violent  in  all  the  peripheral  arteries  which  I  have  just 
named. 

3.  In  arterio-sclerosis  occurring  in  spare,  elderly  men,  with  or 
without  aortic  regurgitation,  one  often  notices  a  lateral  excursion  of 
the  tortuous  brachial  arteries  synchronous  with  every  heart  beat. 
An  up-and-down  pulsation  may  occur  at  the  same  time.  Not  infre- 
quently the  arteries  which  are  stiffened  by  deposition  of  lime  salts 
(see  below,  page  110)  stand  out  visibly  as  enlarged,  tortuous  cords 
upon  the  temple  and  along  the  inner  sides  of  the  biceps  muscle, 
(see  Figs.  61  and  62)  and  occasionally  the  course  of  the  radial  artery 


INSPECTION. 


91 


may  be  traced  over  a  considerable  distance  in  the  forearm.  In  rare 
cases  inequalities  produced  in  the  arterial  wall  by  deposition  of 
lime  salts  may  be  visible  as  well  as  palpable. 

(c)  Capillary  Pulsation. 

If  a  microscopic  slide  is  placed  against  the  mucous  membrane  of 
the  lower  lip  so  as  partially  to  blanch  its  surface,  one  may  see,  with 


FIG.  62.  -Enlarged  and  Tortuous  Brachial  Artery  (Arterio-sclerosls). 

each  beat  of  the  heart  (in  cases  of  aortic  regurgitation  and  sometimes 
in  other  conditions),  a  delicate  flushing  of  the  blanched  surface  be- 
neath the  glass  slide.  The  same  pulsation  is  sometimes  to  be  ob- 
served under  the  finger  nails,  or  may  be  still  better  brought  out  by 
drawing  a  pencil  or  other  hard  substance  across  the  forehead  so  as 
to  cause  a  line  of  hyperaemia,  at  the  edge  of  which  the  systolic  flush- 
ing occurs.  This  phenomenon  will  be  referred  to  again  when  we 
come  to  speak  of  aortic  regurgitation.  Here  it  suffices  to  say  that 
it  is  not  in  any  way  peculiar  to  that  disease,  and  occurs  occasion- 


92  PHYSICAL  DIAGNOSIS. 

ally  in  health,  in  anaemia,  in  exophthalmic  goitre,  and  in  condi- 
tions associated  with  low  tension  in  the  peripheral  arteries,  as  well 
as  in  any  area  of  inflammatory  hyperaemia  (jumping  toothache, 
throbbing  felon,  etc.). 

X.  INSPECTION  OF  THE  SKIN  AND  Mucous  MEMBRANES. 

Light  may  be  thrown  upon  the  diagnosis  of  very  many  diseases 
by  observing  the  color  and  condition  of  the  cutaneous  surfaces  as 
well  as  of  the  mucous  membranes.  We  should  look  for  the  follow- 
ing conditions : 

(1)  Cyanosis. 

(2)  (Edema. 

(3)  Pallor. 

(4)  Jaundice. 

(5)  Scars  and  eruptions. 

(1)   Cyanosis. 

By  cyanosis  we  mean  a  purplish  or  grayish-blue  tint  notice- 
aole  especially  in  the  face,  in  the  lips,  and  under  the  nails.  There 
are  many  degrees  of  cyanosis,  from  the  slight  purplish  tinge  of  the 
lips,  which  a  little  overexertion  or  slight  exposure  to  cold  may  bring 
out,  up  to  the  gray-blue  color  seen  in  advanced  cases  of  pulmonary  or 
cardiac  disease,  or  the  dark  reddish-blue  seen  in  congenital  malfor- 
mations of  the  heart.  Cyanosis  makes  a  very  different  impression 
upon  us  when  it  is  combined  with  pallor  on  the  one  hand  or  with 
jaundice  on  the  other.  When  combined  with  pallor,  one  gets  vari- 
ous ashy-gray  tints,  while  the  admixture  of  cyanosis  and  jaundice 
results  in  a  color  very  difficult  to  describe,  sometimes  approaching 
a  greenish  hue  The  commonest  causes  of  cyanosis  are : 

(a)  Valvular  01  parietal  disease  of  the  heart. 

(b)  Emphysema. 

(c)  Asthma. 

(d)  Pneumonia. 
(«)  Phthisis. 

(/)  In  some  persons  a  certain  degree  of  cyanosis  of  the  lips 
exists  despite  perfect  health.  This  is  especially  true  of  weather- 
beaten  faces  and  those  of  the  so-called  "  full-blooded  "  type. 


INSPECTION.  93 

(<?)  Methsemoglobinaemia,  such  as  occurs  after  the  excessive  use 
of  coal-tar  analgesics  (antifebrine,  etc.). 

A  rare  but  very  striking  type  of  cyanosis  is  that  seen  in  cases 
of  congenital  heart  disease,  in  which  the  lips  may  be  indigo  blue 
in  color  or  almost  black  while  yet  no  dyspnoea  is  present. 

(2)  (Edema. 

(Edema,  or  the  accumulation  of  serous  fluid  in  the  subcutaneous 
spaces,  is  usually  appreciated  by  palpation  rather  than  by  inspec- 
tion, but  sometimes  makes  the  face  look  very  puffy,  especially 
under  the  eyes  This  is  not  a  common  occurrence  in  diseases  of 
the  chest,  in  connection  with  which  such  oedema  as  takes  place  is 
usually  to  be  found  in  the  lower  extremities  and  is  appreciable 
rather  by  palpation  than  by  inspection.  If  we  are  not  familiar  with 
a  patient's  face,  we  often  do  not  perceive  in  it  the  changes  of  out- 
line due  to  cedema  which  a  friend  would  notice  at  once.  Clothing 
is  apt  to  leave  grooves  and  marks  wherever  it  presses  tightly  upon 
the  osdematous  tissues,  as  around  the  waist  or  over  the  shoulders. 
In  the  legs,  the  presence  of  cedema  may  be  suggested  by  an  unnatu- 
rally smooth,  glossy  appearance  of  the  skin  Such  impressions, 
however,  may  be  false  unless  controlled  by  palpation,  for  simple 
obesity  may  produce  very  similar  appearances. 

(3)  Pallor. 

Pallor  suggests,  though  it  does  not  in  any  way  prove,  anaemia, 
and  anaemia  is  a  characteristic  of  the  commonest  of  all  diseases  of 
the  chest — phthisis.  It  is  also  seen  in  certain  varieties  of  cardiac 
disease.  Pallor  of  the  mucous  membranes,  as  seen  in  the  lips  and 
conjunctivas,  is  much  more  apt  to  be  a  sign  of  real  anaemia  than  is 
pallor  of  the  skin.  At  best,  pallor  is  only  a  sign  which  suggests  to 
us  to  look  further  into  the  case  in  one  or  another  direction,  and  of 
itself  proves  nothing  of  importance. 

(4)  Jaundice. 
The  yellowish  tint  which  appears  in  the  skin,  and  especially  in 


94 


PHYSICAL  DIAGNOSIS. 


the  conjunctiva,  when  the  escape  of  bile  from  the  liver  is  hindered, 
is  sometimes  to  be  seen  in  connection  with  uncompensated  heart 
disease  when  the  liver  is  greatly  distended  by  passive  congestion 
Pneumonia  is  occasionally  complicated  by  jaundice;  but  beyond 
this  1  know  of  no  special  connection  between  this  symptom  and 
diseases  of  the  chest. 

(5)  Scars  and  Eruptions. 

In  cases  of  suspected  syphilis  of  the  lung  or  bronchi  the  pres- 
ence of  scars  and  eruptions  suggestive  of  syphilis  may  be  useful  in 
diagnosis. 


FIG.  63.— Sarcoma  of  Sternum  and  Cervical  Glauds.    (Curschmann.) 

XI.  ENLARGED  GLANDS. 

Routine  inspection  of  the  chest  may  reveal  the  presence  of  en- 
larged glands  in  the  neck  or  axillae,  and  may  thereby  give  us  a  clew 


INSPECTION.  95 

to  the  nature  of  some  intrathoracic  disease ;  for  example,  the  pres- 
ence of  enlarged  glands  in  the  neck,  especially  if  there  are  any 
scars,  sinuses,  or  other  evidence  that  snppnration  is  going  on  or 
has  formerly  taken  place  in  them,  suggests  the  possibility  of  pul- 
monary tuberculosis  or  of  an  enlargement  of  the  bronchial  and  me- 
diastinal  glands.  Again,  malignant  disease  of  the  chest  is  some- 
times associated  with  the  metastatic  nodules  over  the  clavicle  (see 
Fig.  63),  and  a  microscopic  examination  of  them  may  thus  reveal 
the  nature  of  the  intrathoracic  disease  to  which  they  are  secondary. 
Very  large  and  matted  masses  of  glands  above  the  clavicle,  which 
have  never  suppurated  and  have  been  painless  and  slow  in  their 
growth,  suggest  the  presence  of  similar  deposits  in  the  mediastinum 
as  a  part  of  the  symptom  complex  known  as  "Hodgkin's  disease." 
The  presence  of  a  goitre  or  enlargement  of  the  thyroid  gland  may 
account  for  a  well-marked  dyspnoea. 

Syphilis  produces  general  glandular  enlargement;  the  posterior 
cervical  and  the  epitrochlear  glands  are  often  involved,  but  this  is 
also  the  case  in  many  diseases  other  than  syphilis. 


CHAPTER  V. 

PALPATION  AND   THE   STUDY  OF  THE  PULSE. 

I    PALPATION. 

THE  most  important  points  to  be  determined  by  palpation — that 
is,  by  laying  the  hand  upon  the  surface  of  the  chest — are : 

(1)  The  position  and  character  of  the  apex  beat  of  the  heart. 

(2)  The  presence  of  a  "  thrill "  (see  below) . 

(3)  The  vibrations  of  the  spoken  voice  ("tactile  fremitus"). 

(4)  The  presence  of  pleuritic  or  pericardial  friction. 

Other  less  important  data  furnished  by  palpation  will  be  men- 
tioned later. 

(1)  The  Apex  Beat. 

(a)  In  feeling  for  the  apex  impulse  of  the  heart,  one  should 
first  lay  the  palm  of  the  hand  lightly  upon  the  chest  just  below  the 
left  nipple      In  this  way  we  can  appreciate  a  good  deal  about  the 
movements  of  the  heart,  and  confirm   or  modify  what  we  have 
learned  by  inspection.     One  learns,  in  the  first  place,  whether  the 
heart  beat  is  regular  or  not,  and  in  case  it  is  irregular,  whether  the 
beats  are  unequal  in  force  or  whether  some  are  skipped ;  further, 
one  gets  a  more  accurate  idea  than  can  be  obtained  through  inspec- 
tion regarding  the  character  of  the  cardiac  movements.     The  power- 
ful heaving  impulse  suggesting  a  hypertrophied  heart,  the  diffuse 
slap  often  felt  in  dilatation  of  the  right  ventricle,  the  sudden  tap 
characteristic  of  mitral  stenosis,  the  deliberate  thrust  occasionally 
met  with  in  aortic  stenosis,  may  be  thus  appreciated. 

(b)  After  this,  it  is  best  to  lay  the  tips  of  two  or  three  fingers 
over  the  point  where  the  maximum  impulse  is  to  be  seen,  and  fol- 
low it  outward  arid  downward  until  one  arrives  at  the  point  farthest 
to  the  left  and  farthest  down  at  which  it  is  still  possible  to  feel 


PALPATION  AND   THE  STUDY  OF  THE  PULSE.  97 

any  up-and-down  movement.  This  point  usually  corresponds  with 
the  apex  of  the  heart,  as  determined  by  percussion.  It  does  not 
correspond  with  the  maximum  cardiac  impulse,  but  is  often  to  be 
found  at  least  an  inch  farther  to  the  left  and  downward  (see  above, 
Fig.  58). 

Sometimes  one  can  localize  by  palpation  a  cardiac  impulse 
which  is  not  visible ;  on  the  other  hand,  in  some  cases  we  can  see 
pulsations  that  we  cannot  feel.  Both  methods  must  be  used  in 
every  case. 

The  results  obtained  by  palpation  and  inspection  of  the  apex 
region  give  us  the  most  reliable  data  that  we  have  regarding  the 
size  of  the  heart.  Percussion  may  be  interfered  with  by  the  pres- 
ence of  gas  in  the  stomach,  of  fluid  or  adhesions  in  the  pleural  cav- 
ity, or  by  the  ineptness  of  the  observer,  but  it  is  almost  always  pos- 
sible with  a  little  care  to  make  out  by  a  combination  of  palpation 
and  inspection  the  position  of  the  apex  of  the  heart.  When  we 
can  neither  feel  it  nor  see  it,  we  may  have  to  fall  back  upon  auscul- 
tation, considsring  the  apex  of  the  heart  to  be  at  or  near  the  point 
at  which  the  heart  sounds  are  heard  loudest.  When  endeavoring 
to  find  the  apex  of  the  heart,  we  must  not  forget  that  the  position 
of  the  patient  influences  considerably  the  relation  of  the  heart  to 
the  chest  walls  If  the  patient  is  leaning  toward  the  left  or  lying 
on  the  left  side,  the  apex  will  swing  out  several  centimetres  toward 
the  left  axilla. 


(2)  "Thrills." 


When  feeling  for  the  cardiac  impulse  with  the  palm  of  the 
hand,  we  are  in  a  good  position  to  notice  the  presence  or  absence 
of  a  very  important  physical  sign  to  which  we  give  the  name  of 
" thrill."  The  feeling  imparted  to  the  fingers  by  the  throat  of 
a  purring  cat  is  very  much  like  the  palpable  "  thrill "  over  the  pre- 
cordia  in  certain  diseases  of  the  heart  to  be  mentioned  later.  It  is 
a  vibration  of  the  chest  wall,  usually  confined  to  a  small  area  in  the 
region  of  the  apex  impulse,  but  sometimes  felt  in  the  second  right 
intercostal  space  or  elsewhere  in  the  precordial  region.  This  vibra- 
tion or  thrill  almost  always  occurs  intermittently,  i.e.,  only  during 
7 


98  PHYSICAL  DIAGNOSIS. 

a  portion  of  the  cardiac  cycle.  When  felt  in  the  apex  region,  it 
usually  occurs  just  before  the  cardiac  impulse.;  this  fact  we  express 
by  calling  it  a  "presystolic  thrill ";  but  occasionally  we  rnay  feel  a 
systolic  thrill  at  the  apex — one,  that  is,  which  accompanies  the  car- 
diac impulse.  The  word  thrill  should  be  used  to  denote  only  a 
purring,  vibrating  sensation  communicated  to  the  fingers  by  the 
chest  wall.  It  is  incorrect  to  speak  of  a  thrill  as  if  it  were  some- 
thing audible. 

We  must  also  distinguish  a  purring  thrill  from  the  slight  shud- 
der or  jarring  which  often  accompanies  the  cardiac  impulse  in  func- 
tional neuroses  of  the  heart  or  in  conditions  of  mental  excitement. 

As  a  rule  we  can  appreciate  a  thrill  more  easily  if  we  lay  the 
fingers  very  lightly  upon  the  chest,  using  as  little  pressure  as  pos- 
sible. Firm  pressure  may  prevent  the  occurrence  of  the  vibrations 
which  we  desire  to  investigate.  Of  the  thrills  felt  over  the  base  of 
the  heart,  more,  will  be  said  in  Chapter  X. 

(3)  Vibrations  Communicated  to  the  Chest  Wall  by  the  Voice. 

"  Tactile  fremitu's  "  is  the  name  given  to  the  sense  of  vibration 
communicated  to  the  hand  if  the  latter  is  laid  upon  the  chest  while 
the  patient  repeats  some  short  phrase  of  words.  The  classical 
method  of  testing  tactile  fremitus  is  to  ask  the  patient  to  count 
"one,  two,  three,"  or  to  repeat  the  words  "ninety-nine  "  Avhile  the 
palm  of  the  hand  is  laid  flat  upon  the  chest.  The  amount  of  fre- 
mitus to  be  obtained  over  a  given  part  of  the  thorax  varies,  of  course, 
according  to  the  loudness  of  the  words  spoken,  and  is  influenced 
also  by  the  vowels  contained  in  them.  A  certain  uniformity  is  ob- 
tained by  getting  the  patient  to  repeat  always  the  same  formula. 
Thus,  he  is  likely  to  use  the  same  amount  of  force  each  time  he  re- 
peats them  and  to  use  approximately  the  same  pitch  of  voice. 

Other  things  being  equal,  the  fremitus  is  greater  in  men  than 
in  women,  in  adults  than  in  children,  and  is  more  marked  in  those 
whose  voices  are  low  pitched  than  in  those  whose  voices  are  rela- 
tively shrill  The  amount  of  fremitus  also  varies  widely  in  differ- 
ent parts  of  the  healthy  chest  A  glance  at  Fig  64  will  help  us  to 
realize  this  The  parts  shaded  darkest  communicate  to  the  fingers 


PALPATION  AND   THE  STUDY  OF  THE  PULSE.  99 

the  most  marked  freinitus,  while  in  the  parts  not  shaded  at  all,  lit- 
tle or  110  fremitus  is  felt  Intermediate  degrees  of  vibration  are 
represented  by  intermediate  tints  of  shading.  From  this  diagram 
we  see  at  once  (a)  that  the  maximum  of  frernitus  is  to  be  obtained 
over  the  apex  of  the  right  lung  in  front,  (b)  that  it  is  greater  in  the 
upper  part  of  the  chest  than  in  the  lower,  and  somewhat  greater 
throughout  the  right  chest  than  in  corresponding  parts  of  the  left. 


FIG.  64.— Distribution  of  Tactile  Fremitus. 

This  natural  inequality  of  the  two  sides  of  the  chest  cannot  be  too 
stronyly  emphasized. 

Comparatively  little  fremitus  is  to  be  felt  t>ver  the  scapulae  be- 
hind, and  still  less  in  the  precordial  region  in  front.  The  outlines 
of  the  lungs  can  be  quite  accurately  mapped  out  by  means  of  the 
tactile  fremitus  in  adults  of  low-pitched  voice.  In  children,  as  has 
been  already  mentioned,  fremitus  is  usually  very  slight  and  may  be 
entirely  absent,  and  in  many  women  it  is  too  slight  to  be  of  any 
considerable  diagnostic  value.  Again,  some  very  fat  persons  and 
those  with  thick  chest  walls  transmit  but  little  vibration  to  their 
chest  walls  when  they  speak.  On  the  other  hand,  in  emaciated 
patients  or  in  those  with  thin-walled,  flexible  chests,  the  amount 
of  fremitus  is  relatively  great. 


100 


PHYSICAL  DIAGNOSIS. 


Bearing  in  mind  all  these  disparities — disparities  both  between 
persons  of  different  age  and  different  sex,  and  between  the  two 

sides  of  the  chest  in  any  one 
person — we  are  in  a  position  to 
appreciate  the  modifications  to 
which  disease  gives  rise  and 
which  may  be  of  great  impor- 
tance in  diagnosis.  These  vari- 
ations are : 

(a)  Diminution   or     absence 
of  frernitus. 

(b)  Increase   or   absence    of 
fremitus. 

(a)  If  the .  lung  is   pushed 
away  from  the  chest  wall  by  the 
presence  of  air  or  fluid  or  tumor 
in  the  pleural  cavity,  we  get  a 
diminution  or  absence  of  tactile 
fremitus — diminution  where  the 
layer  of  fluid  or  air  is  very  thin , 
absence  where  it  is  of  consider- 
able thickness. 

(b)  Solidification  of  the  lung 
due  to  phthisis  or  pneumonia  is 
the  commonest  cause  of  an  in- 

FIG.  65,-Showing  Point  (F)  at  Which  Pleural  .  ,.,       ,,         .,  -p, 

Friction  is  Most  often  Heard.  crease  in  tactile  fremitus.     Fur- 

ther details  as  to  the  variations 

in  amount  of  fremitus  in  different  diseases  may  be  found  in  later 
chapters  of  this  book. 

(4)  Friction,  Pleural  or  Pericardial. 

In  many  cases  of  inflammatory  roughening  of  the  pleural  sur- 
faces ("  dry  pleurisy  ")  a  grating  or  rubbing  of  the  two  surfaces 
upon  each  other  may  be  felt  as  well  as  heard  during  the  movements 
of  respiration,  and  especially  at  the  end  of  inspiration.  Such  fric- 
tion is  most  often  felt  at  the  bottom  of  the  axilla,  on  one  side  or 


PALPATION  AND  THE  STUDY  OF  THE  PULSE. 


101 


the  other,  where  the  diaphragmatic  pleura  is  in  close  apposition 
with  the  costal  layer  (see  Fig.  65,  p.  100). 

Similarly,  in  roughening  of  the  pericardial  surfaces  ("dry"  or 
"  plastic  "  pericarditis)  it  is  occasionally  possible  to  feel  a  grating 
or  rubbing  in  the  precordial  region  more  or  less  synchronous  with 
the  heart's  movements.  Such  friction  is  most  often  to  be  felt  in 
the  region  of  the  fourth  left  costal  cartilage  (see  Fig.  66). 

Palpable  friction  is  of  great  value  in  diagnosis  because  it  is  a 
sign  about  which  we  can  feel  no  doubt ;  as  such  it  frequently  con- 


FIG.  66.— Showing  Point  (P)  at  Which  Pericardial  Friction  is  Most  Often  Heard. 

firms  our  judgment  in  cases  in  which  the  auscultatory  signs  are  less 
clear.  Friction  sounds  heard  with  the  stethoscope  may  be  closely 
simulated  by  the  rubbing  of  the  stethoscope  upon  the  skin,  but  pal- 
pable friction  is  simulated  by  nothing  else,  unless  occasionally  by 

(5)  Palpable  Rales. 

Occasionally  coarse,  dry  rales  communicate  a  sensation  to  the 
hand  placed  upon  the  chest  in  the  region  beneath  which  the  rales 
are  produced ;  to  the  practised  hand  this  sensation  is  quite  differ- 
ent from  that  produced  by  pleural  friction,  although  the  difference 
is  hard  to  describe. 


102 


PHYSICAL   DIAGNOSIS. 


(6)  Tender  points  upon  the  thorax. 

In  mitral  disease,  dry  pleurisy,  necrosis  of  the  rib,  and  some- 
times in  phthisis,  one  finds  areas  of  marked  tenderness  in  different 
parts  of  the  chest.  The  position  of  the  tender  points  in  intercostal 
neuralgia  generally  corresponds  with  the  point  of  exit  of  the  inter- 
costal nerves.  These  points  are  shown  in  Fig.  67. 

The  tenderness  in  phthisis  is  most  apt  to  be  in  the  upper  and 
front  portions  of  the  chest.  In  neurotic  individuals  we  sometimes 
find  a  very  superficial  tenderness  over  parts  of  the  thorax ;  in  such 


FIG.  67.— Showing  Points  of  Exit  of  the  Intercostal  Nerves. 

cases  pain  is  produced  by  very  light  pressure,  but  not  by  firm  press- 
ure at  the  same  point. 

(7)  The  presence  of  pulsations  in  parts  of  the  chest  where  nor- 
mally there  should  be  none  is  suggested  by  inspection  and  con- 
firmed by  palpation.     It  is  not  necessary  to  repeat  what  was  said 
above  as  to  the  commonest  causes  of  such  abnormal  pulsations. 
When  searching  for  slight,  deep-seated   pulsation   (e.g.,  from  an 
aortic  aneurism),  it  is  well  to  use  bimanual  palpation,  keeping  one 
hand  on  the  front  of  the  chest  and  the  other  over  a  corresponding 
area  in  the  back. 

(8)  Fluctuation  or  elasticity  in  any  tumor  or  projection  from 


PALPATION  AND  STUDY  OF  THE  PULSE.  103 

the  chest  is  a  very  important  piece  of  information  which  palpation 
may  give  us. 

(9)  The  temperature  and  quality  of  the  skin  are  often  brought 
to  our  attention  during  palpation.  After  a  little  practice  one  can 
usually  judge  the  temperature  within  a  degree  or  two  simply  from 
the  feeling  of  the  skin.  Any  roughness,  dryness,  or  loss  of  elas- 
ticity of  the  skin  (myxoedema,  diabetes,  long-standing  pyrexia,  or 
wasting  disease)  is  easily  appreciated  as  we  pass  the  hand  over  the 
surface  of  the  thorax  or  down  the  arms.  The  same  manipulation 
often  brings  to  our  attention  in  cases  of  alcoholism  an  unusually 
smooth  and  satiny  quality  of  the  cutaneous  surface. 

II.  THE  PULSE. 

Fifty  years  ago  the  study  of  the  pulse  furnished  the  physician 
with  most  of  the  available  evidence  regarding  the  condition  of  the 
heart.  At  present  this  is  not  the  case.  With  the  increase  of  our 
knowledge  of  the  direct  physical  examination  of  the  heart  and  of 
the  various  methods  of  measuring  the  systolic  or  diastolic  pressure 
on  the  peripheral  arteries,  the  amount  of  information  furnished 
exclusively  by  the  pulse  has  proportionately  decreased,  until  to- 
day, I  think,  it  is  a  fact  that  there  is  but  little  to  be  learned  by 
studying  the  pulse  which  could  not  be  as  well  or  better  ascertained 
by  examining  the  heart  and  measuring  the  arterial  pressure. 

Nevertheless,  the  radial  pulse  is  still  an  important  factor  in  diag- 
nosis, prognosis,  and  treatment,  and  will  remain  so,  because  it  gives 
us  quickly,  succinctly,  and  in  almost  every  case  a  great  deal  of  valu- 
able information  which  it  would  take  more  time  and  trouble  to  ob- 
tain in  any  other  way.  As  we  feel  the  pulse,  we  get  at  once  a  fact 
of  central  importance  in  the  case;  by  the  pulse  the  steps  of  our  sub- 
sequent examination  are  guided.  In  emergencies  or  accidents  the 
pulse  gives  us  our  bearings  and  tells  us  whether  or  not  the  patient's 
condition  is  one  demanding  immediate  succor — e.g. ,  hypodermic 
stimulation — and  whether  the  outlook  is  bright  or  dark.  To  gather 
this  same  information  in  any  other  way  would  involve  losing  valu- 
able time. 

Again,  when  one  has  to  to  see  a  large  number  of  patients  in  a 


104  PHYSICAL  DIAGNOSIS. 

short  time,  as  in  visiting  a  hospital  ward  or  on  the  crowded  days  of 
private  practice,  the  pulse  is  an  invaluable  short  cut  to  some  of  the 
most  important  data. 

Moreover,  there  are  some  important  inferences  which  the  pulse 
and  only  the  pulse  enables  us  to  make.  They  are  not  numerous,  but 
their  value  may  be  great.  Delay  in  one  radial  pulse  when  taken  in 
connection  with  other  signs  may  furnish  decisive  evidence  of  aneu- 
rism of  the  aortic  arch ;  aortic  stenosis  is  a  lesion  which  cannot  be 
diagnosed  unless  the  pulse  shows  certain  characteristic  features; 
arterial  degeneration  may  betray  its  presence  chiefly  in  the  periph- 
eral arteries. 

Since,  then,  the  condition  of  the  pulse  furnishes  information  of 
crucial  importance  in  a  few  diseases,  and  is  a  quick,  reliable,  and 
convenient  indication  of  the  general  condition  of  the  circulation  in 
all  cases,  it  is  essential  that  we  should  study  it  most  carefully  both 
in  health  and  in  disease. 

How  to  Feel  the  Pulse. 

(a)  We  usually  feel  for  the  pulse  in  the  radial  artery  because 
this  is  the  most  superficial  vessel  which  is  readily  available.     Oc- 
casionally, as  when  the  wrists  are  swathed  in  surgical  dressings  or 
tied  up  in  a  straight-jacket,  we  make  use  of  the  temporal,  facial, 
or  carotid  arteries. 

(b)  Both  radials  should  always  be  felt  at  the  same   time.     By 
making  this  a  routine  practice  many  mistakes  are  avoided  and  any 
difference  in  the  two  pulses  is  appreciated. 

(c)  The  tips  of  three  fingers  (never  the  thumb)  should  be  laid 
upon  the  artery,  and  the  following  points  noted : 

1.  The  rate  of  the  pulse. 

2.  The  rhythm  of  the  pulse  (regular  or  irregular). 

3.  The  amount  of  force  necessary  to  obliterate  it  (compressi- 
bility). 

4.  The  size  and  shape  of  the  pulse  wave. 

5.  The  extent  to  which   the  artery  collapses  between  beats 
(tension). 

6.  The  size  and  position  of  the  artery. 


PALPATION  AND  THE  STUDY  OF  THE  PULSE.        105 

7.   The  condition  of  the  artery  walls. 

Each  of  these  points  will  now  be  considered  in  detail. 

1.    The  Rate  of  the  Pulse. 

In  the  adult  male  the  pulse  averages  72  to  the  minute,  in  the 
female  80.  In  children  it  is  considerably  more  frequent.  At  birth 
it  averages  about  130?  and  until  the  third  year  it  is  usually  above 
100.  In  some  families  as  low  pulse,  60  or  less,  is  hereditary ;  on  the 
other  hand,  it  is  not  very  rare  to  observe  a  permanent  pulse  rate  of 
100  or  more  in  a  normal  adult  (see  below,  p.  261).  Exercise  or  emo- 
tion quickens  the  pulse  very  markedly,  and  after  food  it  is  somewhat 
accelerated.  Some  account  of  the  causes  of  pathological  quicken- 
ing or  slowing  of  the  pulse  will  be  found  on  pages  261  and  262. 

2.   Rhythm. 

The  pulse  may  be  irregular  in  force,  in  rhythm,  or  (as  most 
commonly  happens)  in  both  respects.  As  a  rule,  irregularities  in 
force  are  the  more  serious.  Intermitteuce  or  irregularity  in  rhythm 
alone,  means  that  the  heart  skips  one  or  more  beats  at  regular  or 
irregular  intervals.  This  may  be  a  mere  idiosyncrasy  not  associ- 
ated with  any  evidence  of  disease.  I  have  known  several  instances 
in  which  a  perfectly  sound  person  has  been  aware  of  such  an  irregu- 
larity throughout  life — the  heart  dropping  regularly  every  third  or 
fourth  beat.  Such  rhythmical  interrnittence  in  health  is  not  un- 
common. 

AVhen  beats  are  dropped,  not  at  fixed  intervals,  but  irregularly, 
the  pulse  waves  usually  vary  in  force  as  well.  This  combination 
of  irregular  cardiac  rhythm  with  variations  in  the  strength  of  the 
individual  beats  is  very  rarely  seen  in  health  and  usually  points  to 
functional  or  structural  disease  of  the  heart. 

Special  types  of  irregularity  will  be  discussed  later. 

In  general  it  may  be  said  (a}  that  irregularity  in  the  force  of 
the  pulse  beats  is  a  serious  sign,  if  overexertion  and  temporary 
toxic  influences  (tobacco,  tea,  etc.)  can  be  ruled  out;  (b)  that  it  is 
far  more  serious  when  occurring  in  connection  with  diseases  of  the 


106  PHYSICAL  DIAGNOSIS. 

aortic  valve  than  in  mitral  disease ;  and  (c)  that  it  often  occurs  in 
connection  with  sclerosis  of  the  coronary  arteries  and  myocarditis. 

3.    Compressibility,  or  Systolic  Arterial  Pressure. 

There  is  no  single  datum  concerning  the  pulse  more  important 
than  the  amount  of  force  needed  to  obliterate  its  beat.  Until 
recently  we  have  had  no  more  accurate  method  of  measuring  the 
systolic  blood  pressure  than  the  following :  Let  the  tips  of  three 
fingers  rest  as  usual  on  the  radial  artery.  Then  gradually  increase 
the  pressure  made  upon  the  vessel  with  the  finger  nearest  the  pa- 
tient's heart  until  the  pulse  wave  is  arrested  and  cannot  be  felt  by 
the  other  fingers  which  rest  loosely  on  the  artery.  The  degree  of 
force  necessary  to  arrest  the  wave  varies  a  great  deal  in  different 
cases  and  at  different  times  of  day,  but  by  trying  the  above  manoeuvre 
day  after  day  in  as  many  cases  as  possible,  and  especially  by  com- 
paring one's  impressions  with  accurate  measurements  of  blood  press- 
ure (vide  infra),  one  comes  to  possess  a  fairly  accurate  mental 
standard  with  Avhich  to  compare  abnormal  cases.  Sometimes  the 
circulation  through  the  palmar  arch  is  so  active  that  one  must  cut  off 
the  radial  pulse  below  as  well  as  above  the  point  at  which  we  are 
palpating  it. 

The  compressibility  of  the  pulse  is  a  rough  measure  of  the  mus- 
cular power  of  the  heart's  beat,  and  therefore  gives  us  direct  infor- 
mation about  this  important  element  in  the  patient's  condition. 

4-   The  Size  and  Shape  of  the  Pulse   Wave. 

Of  the  use  of  the  sphygmograph  for  representing  pulse  waves 
I  shall  speak  later.  The  points  discussed  in  this  section  are  appre- 
ciable to  the  fingers. 

I.  The  size  of  the  pulse  wave — the  height  to  which  it  lifts  the 
finger — depends  on  two  factors : 

(a)  The  force  of  the  cardiac  contractions  (systolic  arterial 
pressure). 

(&)  The  tightness  or  looseness  of  the  artery  (tension,  or  diastolic 
pressure). 

If  the  arteries  are  contracted  and  small,  the  pulse  wave  corre- 


PALPATION  AND  THE  STUDY  OF  THE  PULSE.        107 

spends,  while  if  they  are  large  and  relaxed,  it  needs  only  a  moder- 
ate degree  of  power  in  the  heart  to  produce  a  high  pulse  wave.  If 
the  tension  remains  constant  the  size  of  the  pulse  wave  depends  on 
the  force  of  the  heart's  contraction.  If  the  heart  power  remains 
constant,  the  size  of  the  pulse  wave  depends  on  the  degree  of  vas- 
cular tension.  Vascular  tension  is  estimated  in  ways  to  be  de- 
scribed presently,  and  after  allowing  for  it,  we  are  enabled  to  esti- 
mate the  power  of  the  heart's  contractions  from  the  height  of  the 
pulse  wave. 

II.  The  shape  of  the  pulse  wave  is  also  of  importance. 

(a)  It  may  have  a  very  sharp  summit,  rising  and  falling  back 
again  suddenly;  this  is  known  as  an  ill-sustained  pulse,  and  may 
be  due  to  a  lack  of  sustained  propulsive  power  in  the  contracting 
heart  muscle,  to  low  vascular  tension,  or  to  a  combination  of  the 
two  causes.  A  weak  heart  with  low  arterial  tension  often  produces 
such  a  pulse  wave — deceptively  high  and  giving  at  first  an  impres- 
sion of  power  in  the  heart  wall,  but  ill  sustained  and  easily  com- 
pressible. This  is  the  "  bounding  pulse  "  of  early  infectious  proc- 
esses. An  exaggeration  of  this  type  of  pulse  is  to  be  felt  in  aortic 
regurgitation  (sfee  page  232). 

(&)  In  sharp  contrast  with  the  above  is  the  pulse  wave  which 
lifts  the  finger  gradually  and  slowly,  sustains  it  for  a  relatively 
long  period,  and  then  sinks  gradually  down  again.  Such  a  pulse 
with  a  "  long  plateau  "  instead  of  a  sharp  peak  is  to  be  felt  most 
distinctly  in  aortic  stenosis,  less  often  in  mitral  stenosis  and  other 
conditions  (see  page  242). 

(c)  The  dicrotic  pulse  wave  is  one  in  which  the  secondary  wave, 
which  the  sphygmograph  shows  to  be  present  in  the  normal  pulse, 
is  much   exaggerated,   so  that  a  distinct  "echo"  of  the  primary 
wave  is  felt  after  each  beat.     If  the  heart  is  acting  rapidly,  this 
dicrotic  wave  does  not  have  time  to  fall  before  it  is  interrupted  by 
the  primary  wave  of  the  next  beat,  and  so  appears  in  the  sphygmo- 
graphic  tracing  as  a  part  of  the  up-stroke  of  the  primary  wave. 
This  is  known  as  the  "  anacrotic  pulse." 

(d)  The  shape  of  the  high-tension  pulse  wave  will  be  described 
ii    the  next  paragraph. 


108 


PHYSICAL  DIAGNOSIS 


5    Tension,   or  Diastolic  Arterial  Pressure. 

The  degree  of  contraction  of  the  vascular  muscles  determines 
the  size  of  the  artery  and  (to  a  great  extent)  the  tension  of  the 
blood  within  it.  But  if  the  heart  is  acting  feebly,  there  may  be  so 
little  blood  in  the  arteries  that  even  when  tightly  contracted  they 
do  not  subject  the  blood  within  them  to  any  considerable  degree  of 
tension.  To  produce  high  tension,  then,  we  need  two  factors  •  a 


FIG.  68.-Sphygmographic  Tracing  of  Low  Tension  Pulse. 

certain  degree  of  power  in  the  heart  muscle,  and  contracted  arteries. 
To  produce  low  tension  we  need  only  relaxation  of  the  arteries,  and 
the  heart  may  be  either  strong  or  weak. 

The  pulse  of  low  tension  collapses  between  beats,  so  that  the  ar- 
tery is  less  palpable  than  usual  or  cannot  be  felt  at  all.     Normally, 


FIG.  69.— Sphygmographic  Tracing  of  High  Tension  Pulse. 

the  artery  can  just  be  made  out  "between  beats,  and  any  consider- 
able lowering  of  arterial  tension  makes  it  altogether  impalpable 
except  during  the  period  of  the  primary  wave  and  of  the  dicrotic 
wave,  which  is  often  very  well  marked  in  pulses  of  low  tension. 
The  shape  of  the  wave  under  these  conditions  has  already  been 
described  (see  Fig.  68). 


PALPATION  AND  THE  STUDY  OF  THE  PULSE.        109 

The  pulse  of  high  tension  is  perceptible  between  beats  as  a  dis- 
tinct cord  which  can  be  rolled  between  the  fingers,  like  one  of  the  ten- 
dons of  the  wrist.  It  is  also  difficult  to  compress  in  most  cases,  but 
this  may  depend  rather  011  the  heart's  power  than  on  the  degree 
of  vascular  tension.  A  high-tension  pulse  is  often  indistinguishable 
from  one  stiffened  by  arteriosclerosis  (vide  infra}.  The  pulse  wave 
is  usually  of  moderate  height  or  low,  and  falls  away  slowly  with 
little  or  no  dicrotic  wave  (see  Fig.  69). 

6.    The  Size  and  Position  of  the  Artery. 

I  have  often  known  errors  to  occur  because  a  small  artery  is 
mistaken  for  a  small  pulse  wave.  The  size  of  the  branches  of  the 
arterial  tree  varies  a  great  deal  in  different  individuals  of  the  same 
weight  and  height,  and  if  the  radial  is  unusually  small  and  a  hur- 
ried observation  gives  us  the  impression  (true,  so  far  as  it  goes)  that 
there  is  very  little  in  the  way  of  a  pulse  to  be  felt,  we  are  apt  to 
conclude  (wrongly,  perhaps)  that  the  heart's  work  is  not  being 
properly  performed.  The  effort  to  obliterate  such  a  pulse,  how- 
ever, may  set  us  right  by  showing  that  despite  the  small  size  of  the 
vessel  (and  consequently  of  the  pulse  wave)  it  takes  as  much  force 
as  it  normally  does  to  obliterate  it.  But  in  many  cases  we  can 
determine  the  question  satisfactorily  often  by  using  some  instru- 
ment for  measuring  arterial  pressure.  Thus,  a  small  pulse  wave  (in 
a  congenitally  small'  artery)  may  be  distinguished  from  a  weak 
pulse.  From  the  contracted  artery  of  high  vascular  tension  we  dis- 
tinguish the  congenitally  small  artery  because  the  latter  is  not  to  be 
rolled  beneath  the  fingers,  and  is  not  more  than  normally  palpable 
between  the  pulse  beats. 

Not  infrequently  the  nurse  reports  in  alarm  that  the  patient  has 
no  pulse,  when  in  reality  the  pulse  is  excellent  but  the  artery  mis- 
placed so  as  to  be  impalpable  in  the  ordinary  situation.  It  may  be 
simply  more  deeply  set  than  normal,  so  that  the  fingers  cannot  get 
at  it,  or  it  may  run  superficially  over  the  end  of  the  radius  toward 
the  "anatomical  snuff  box."  Other  anomalies  are  less  common. 
As  a  rule,  the  other  radial  artery  is  normally  placed  and  can  be  used 


110  PHYSICAL  DIAGNOSIS. 

as  a  standard,  but  occasionally  both  radials  are  anomalous  and  we 
may  be  compelled  to  use  the  temporal  or  facial  instead. 

7.   The  Condition  of  the  Artery  Watts. 

Arterio-sclerosis  is  manifested  in  the  peripheral  arteries  in  the 
following  forms : 

(a)  Simple  stiffening  of  the  arteries  without  calcification. 

(b)  Tortuosity  of  the  arteries 

(c)  Calcification. 

Simple  stiffening  without  calcification  is  due  to  fibrous  thicken- 
ing of  the  intiina  and  produces  a  condition  of  the  arteries  not  al- 
ways to  be  distinguished  from  high  tension.  The  artery  can  be 
rolled  under  the  fingers,  stands  out  visibly  between  the  heart's 
beats,  but  is  not  incompressible,  has  a  smooth  surface,  and  is  not 
always  tortuous.  If  it  is  tortuous  as  well  as  stiff,  we  may  con- 
clude that  there  is  endarteritis  at  any  rate,  whether  or  not  there  is 
increased  tension  as  well.  In  the  vast  majority  of  cases  the  two 
conditions  are  asssociated  and  do  not  need  to  be  distinguished. 

The  normal  radial  artery  is  straight  j1  hence  any  deviation  is 
evidence  of  changes  in  its  walls  and  is  easily  recognized  as  we  run 
our  fingers  up  and  down  the  vessel. 

Calcification  of  the  radial  produces  usually  a  beading  of  its  sur- 
face. As  we  move  the  fingers  along  the  artery,  quickly  and  with 
very  slight  pressure,  a  series  of  transverse  ridges  or  beads  can  be 
felt.  The  qualities  of  the  pulse  wave  within  can  usually  be  appre- 
ciated fairly  well,  in  this  type  of  artery,  but  in  very  advanced  cases 
the  calcification  is  diffuse  and  converts  the  radial  into  a  rigid  "pipe 
stem  " — absolutely  incompressible — unless  we  break  the  calcified 
coat — and  easily  mistaken  for  a  tendon.  In  such  an  artery  no 
pulse  can  be  felt. 

Such  are  the  points  to  be  observed  in  feeling  the  pulse.  To 
enumerate  the  characteristics  of  the  pulse  in  the  many  diseases  in 
which  it  affords  us  valuable  information  is  beyond  the  scope  of  this 
book.  The  qualities  to  be  expected  in  the  pulse  in  connection  with 
the  different  diseases  of  the  heart  are  described  in  the  sections  on 

1  Tortuosity  in  the  temporal  artery,  however,  is  normal. 


PALPATION  AND   THE  STUDY  OF  THE  PULSE.          Ill 

those  diseases.  Here  it  will  suffice  to  enumerate  some  of  the  con- 
ditions in  which  vascular  tension  is  usually  increased  or  diminished. 

Low  tension  is  produced  by  moderate  exercise,  by  warmth  (e.g., 
a  warm  bath),  by  food.  Among  pathological  conditions  we  may 
mention,  Addison's  disease,  tuberculosis,  debility,  and  fever. 

High  tension  is  produced  by  cold  (e.g.,  cold  bathing,  malarial 
chills) ,  and  by  constipation  (in  some  cases) .  As  a  rule,  the  tension 
of  the  pulse  increases  with  age  and  is  high  after  the  fiftieth  year. 
Hysteria  and  migraine  are  often  associated  with  increased  vascular 
tension.  Most  frequent  among  pathological  conditions  as  causes 
of  high  tension  are  chronic  nephritis  and  arterio-sclerosis  with  the 
various  diseases  in  which  arterio-sclerosis  is  a  factor  (gout,  alcohol- 
ism, lead  poisoning,  diabetes  of  fat  old  people,  chronic  bronchitis 
with  emphysema). 

In  valvular  heart  disease  without  nephritis  or  arterio-sclerosis 
the  tension  is  usually  normal  or  slightly  lowered. 

ARTERIAL  PRESSURE  AND  THE  INSTRUMENTS  FOR  MEASURING  IT. 

Within  the  past  few  years  a  number  of  instruments  have  come 
into  use,  the  object  of  which  is  to  tell  us  with  some  approach  to 
accuracy  the  lateral  pressure  in  the  peripheral  arteries.  We  have 
long  attempted  to  estimate  this  pressure,  by  simple  digital  com- 
pression and  palpation,  and  no  doubt  these  methods  in  the  hands  of 
skilled  observers  will  always  have  a  field  of  usefulness ;  but  it  seems 
to  me  clear  that  by  the  instruments  about  to  be  described  we  can 
obtain  data  in  regard  to  the  force  of  the  heart's  contractions  and  the 
tension  of  the  peripheral  arteries  more  accurate  and  more  reliable 
than  those  furnished  by  digital  examination.  This  is  especially 
true  of  comparative  records,  as,  for  example,  if  one  attempts  to 
compare  the  tension  of  the  pulse  to-day  with  what  it  was  yesterday, 
when  one  has  felt  many  pulses  in  the  interim.  Another  objection 
to  estimates  of  pulse  pressure  based  on  digital  examination  results 
from  the  fact  that  the  size  of  the  artery  itself  is  apt  to  be  a  confus- 
ing factor. 

Among  the  many  instruments  introduced  within  the  past  few 
years  we  may  distinguish  (1)  those  which  aim  to  estimate  the 


112  PHYSICAL  DIAGNOSIS. 

amount  of  compression  which,  has  to  be  exerted  upon  a  given  artery 
in  order  to  arrest  the  onward  flow  of  blood  in  it,  and  (2)  those 
which  seek  to  estimate  the  amount  of  pressure  in  a  given  artery 
at  the  moment  when  its  wall  makes  the  widest  excursion  or  oscilla- 
tion. 

Instruments  of  the  first  type  are  said  to  measure  systolic  press- 
ure, and  those  of  the  second  type  to  measure  diastolic  pressure. 
Cinder  the  first  heading  I  shall  describe  the  Riva-Rocci  and  Gaert- 
ner  instruments.  Under  the  second  that  of  Oliver  and  that  of  Hill 
and  Barnard. 

1.  Gaertner' s  Tonometer. — The  end  of  a  finger  is  made  blood- 
less by  rolling  up  over  it  a  tight  rubber  ring.  Over  the  blanched 
finger  tip  one  next  applies  a  pneumatic  ring,  which  can  be  inflated 
by  means  of  a  rubber  bulb,  while  the  tension  within  is  meas- 
ured by  a  manometer  connected  with  it.  The  manometer  may  be 
either  of  the  mercury  or  the  spring  type.  To  use  the  instrument 
we  inflate  the  pneumatic  ring  until  the  pressure  recorded  in  the 
manometer  is  considerably  above  what  we  expect  in  the  case  dealt 
with.  (The  tip  of  the  finger  all  this  time  remains  blanched. )  Next 
we  relax  the  tension  within  the  pneumatic  ring,  by  gradually  releas- 
ing the  pressure  exerted  upon  the  inflation  bulb,  until  the  red  color 
reappears  in  the  finger  tip.  Just  as  the  color  reappears  we  note  the 
pressure  in  the  manometer.  This  figure  Avas  supposed  by  Gaertner 
to  represent  the  average  or  mean  pressure  in  the  arteries,  but  it 
has  been  very  generally  conceded  by  other  observers  that  the  figures 
given  by  this  instrument  are  xmuch  nearer  to  those  of  systolic  press- 
ure, that  is,  to  the  pressure  during  the  systole  of  the  left  ventricle 
or  to  the  crest  of  the  pulse  wave. 

The  advantages  of  the  Gaertner  instrument  are  its  compactness 
and  portability.  Its  disadvantages  are  that  (in  this  climate  at  any 
rate)  it  is  very  apt  to  get  out  of  order,  that  it  is  not  suited  to  esti- 
mating pressures  in  any  of  the  dark-skinned  races,  and  that  its 
readings  are  very  much  affected  by  vasomotor  influences,  such  as 
nervousness  or  cold.  If  the  fingers  are  cold  it  may  be  almost  im- 
possible to  make  a  satisfactory  record  with  the  instrument.  Further, 
the  spring  manometer,  like  all  instruments  of  this  type,  is  very  apt 


ARTERIAL  PRESSURE. 


113 


to  get  out  of  order,  and  if  the  mercury  manometer  is  employed  the 
instrument  loses  its  only  advantage,  namely,  its  compactness. 

2.  The  Riva-Rocci  Instrument. — This  instrument  consists  essen- 
tially of  an  inflatable  rubber  armlet,  so  arranged  that  it  can  be  fitted 
closely  around  the  upper  arm,  a  mercury  manometer  of  the  ordinary 
type,  and  an  air-pump  (see  Fig.  70).  The  air  forced  from  the 


FIG.  70. — Stanton's  Modification  of  the  Riva-Rocci  Instrument.     (By  permission  from  the  Unl 
versity  of  Pennsylvania  Medical  Bulletin.) 

pump  is  distributed  into  the  rubber  armlet  and  into  the  man- 
ometer at  the  same  time,  and  experiments  have  shown  that  the 
actual  pressure  in  the  armlet  is  practically  identical  at  any  given 
time  with  that  in  the  manometer.  To  use  the  instrument  we  pump 
in  air  until  the  radial  pulse  stops,  and  at  that  instant  note  the 
height  of  the  mercury  column.  The  reading  thus  obtained  is 
8 


114  PHYSICAL  DIAGNOSIS. 

taken  to  fepreseut  the  systolic  or  maximum  pressure  in  the  brachial 
artery. 

It  is  true  that  the  air  within  the  rubber  armlet  has  to  overcome 
not  only  the  pressure  within  the  radial  artery,  but  the  resistance  of 
the  artery  wall  and  the  elasticity  of  the  soft  parts  around  it.  The 
former  factor  has  been  shown  to  represent  a  pressure  of  not  more 
than  2  or  3  mm.  Hg,  provided  the  artery  walls  are  normal.  If 
arterio-sclerosis  is  present,  it  has  been  estimated  by  Herringham 
that  the  artery  may  oppose  a  resistance  of  15  to  20  mm.  Hg.  The 
amount  of  error  thus  introduced,  however,  is  not  of  importance 
except  when  we  are  trying  to  distinguish  arterio-sclerosis  from 
nephritis  as  a  cause  of  high  tension.  Here  the  instrument  is  unre- 
liable and  we  must  fall  back  upon  the  data  of  arterial  palpation 
(roughness,  tortuosity),  urinary  examination,  etc. 

The  resistance  of  the  soft  parts  around  the  artery  is  a  factor  of 
considerable  importance,  provided  the  compressing  armlet  is  as 
narrow  as  many  of  those  supplied  with  Riva-Rocci  instruments. 
But  if  a  wider  armlet  of  about  seventeen  centimetres  width  is 
used,  according  to  the  recommendation  of  von  Recklinghausen  and 
Stanton,  we  find  that  the  pressure  is  practically  the  same  in  a  given 
individual  whether  the  armlet  is  applied  round  the  upper  arm, 
round  the  forearm,  or  round  the  thigh.  Now  if  the  resistance  of 
the  tissues  of  the  thigh  exerts  no  greater  influence  than  that  of  the 
upper  arm  or  forearm,  it  seems  safe  to  conclude  that  this  factor  may 
be  neglected  as  a  source  of  error  in  comparative  measurements  with 
arms  of  different  sizes. 

The  instrument  is  a  very  simple  and  quick  one  to  use,  needing 
very  little  practice  and  not  more  than  a  minute  or  a  minute  and  a 
half  for  a  single  reading.  The  chief  objection  to  it  is  its  bulk  and 
fragility. 

3.  The  Instrument  of  Hill  and  Barnard. — In  essentials  this  in- 
strument is  like  the  Riva-Rocci,  except  that  all  the  connecting  tubes 
are  rigid,  and  that  in  place  of  the  mercury  manometer  a  very  deli- 
cate aneroid  instrument  is  employed  to  record  the  pressures  within 
the  armlet  (see  Fig.  71).  The  delicacy  of  this  form  of  manometer 
is  so  great  that  with  rigid  connections  it  is  possible  to  register  the 


ARTERIAL  PRESSURE. 


115 


oscillations  of  the  artery  wall  and  to  estimate  the  amount  of  press- 
ure within  the  armlet  at  the  time  when  the  arterial  oscillations  are 
widest ;  in  other  words,  when  the  arteries  are  slackest.  The  work 
of  Howell  and  Brush  has  demonstrated  to  my  satisfaction  that  the 
pressure  at  the  time  of  the  maximum  oscillation  corresponds  to  the 
minimum  or  diastolic  pressure  within  the  arteries. 

The  Hill  and  Barnard  instrument,  when  in  good  order,  seems  to 


FIG.  71.— Hill  &  Barnard's  Sphygmometer. 


me  on  the  whole  the  best  among  those  that  are  clinically  available 
for  measuring  diastolic  pressure.  The  difficulty  of  reading  it  is  less 
than  with  most  other  instruments  designed  for  this  purpose,  and 
the  only  serious  drawback  to  the  instrument  is  the  likelihood  that 
the  manometer  will  get  out  of  order,  a  difficulty  to  which  all  in- 
struments of  this  type  are  very  prone. 

4.  The  Oliver  Instrument. — This  instrument  is  intended,  like  the 
last,  for  estimating  the  pressure  in  the  arteries  during  the  period  of 
maximum  oscillation.  This,  as  I  have  said,  corresponds  in  my 
opinion  to  the  diastolic  and  not  to  the  average  or  mean  pressure. 
A  small  rubber  capsule  filled  with  water  is  placed  upon  the  radial 
artery,  and  through  this  the  pulsations  of  the  artery,  under  differ- 
ent pressures,  are  transmitted  directly  by  a  straight  rod  to  a  spring 


116  PHYSICAL  DIAGNOSIS. 

manometer,  Avhere  the  oscillations  and  pressures  are  recorded  in 
mm.  Hg  (see  Fig  72).  The  instrument  is  a  very  compact  and 
simple  one,  and  if  it  were  not  constantly  getting  out  of  order,  would 
be,  I  think,  of  considerable  value,  although  it  is  a  difficult  instru- 


FIG.  72.— Oliver's  Haemodynamometer. 

mant  to  use.     Its  readings,  however,  soon  become  inaccurate  and 
cease  to  correspond  with  the  mercury  column. 

Stan  ton  (  University  of  Penn,  Med.  Bull.,  February,  1903)  has 
succeeded  in  fitting  a  Riva-Rocci  instrument  with  rigid  connecting 
tubes,  so  that  with  this  single  instrument  he  can  record  both  maxi- 
mum and  minimum  pressures.  The  maximum  or  systolic  pressure 
he  records  in  the  ordinary  way.  To  get  the  minimum  or  diastolic 
pressure  he  clamps  off  the  tube  leading  to  the  inflation  bulb,  and 
then  lets  out  the  air  little  by  little  until  the  mercury  begins  to  oscil- 
late in  the  tube.  The  oscillations  increase  in  extent  up  to  a  maxi- 
mum as  the  air  is  steadily  let  out,  and  then  decrease  again  until 
they  are  lost.  The  reading"  for  diastolic  pressure  is  taken  when  the 
mercury  shows  the  greatest  extent  of  oscillation  in  the  tube. 


ARTERIAL  PRESSURE.  117 

The  readings  thus  obtained,  however,  are  very  inaccurate.  The 
instrument  devised  by  Erlanger  (Johns  Hopkins  Hospital  Reports, 
190-4,  Vol.  XII.)  gives  very  accurate  readings  both  for  systolic  and 
for  diastolic  pressure.  Its  bulk,  delicacy,  the  difficulty  of  keeping 
it  in  good  order,  and  the  amount  of  time  needed  to  secure  a  reading 
will  prevent  its  general  use  in  clinical  work. 

The  Use  of  the  Data  Obtained  by  these  Instruments. 

Whenever  it  is  important  for  us  to  know  the  tension  of  the 
peripheral  arteries,  a  sphygmoinanometer  is  indispensable.  The 
more  I  use  the  instrument,  the  more  firmly  I  am  convinced  that 
digital  measures  of  blood  pressure  are  often  ludicrously  wrong.  The 
Riva-Rocci  instrument  as  modified  by  Janeway  or  Stanton  has  now 
secured  a  firm  position  in  the  routine  work  of  good  clinicians  all  over 
this  country.  Especially  in  relation  to  the  diagnosis  of  nephritis 
the  instrument  is  often  indispensable,  yielding  results  more  signifi- 
cant than  urinary  examination,  and  setting  our  diagnosis  right  when 
it  would  otherwise  have  been  wrong. 

For  the  detection  of  arterio-sclerosis,  Addison's  disease,  tuber- 
culosis, intracranial  hemorrhage  or  tumor,  in  the  study  of  uraemia, 
eclampsia,  and  other  causes  of  coma,  the  instrument  is  also  of  great 
value. 


CHAPTER  VI 

PERCUSSION. 

I.  TECHNIQUE. 

THERE  is  no  other  method  of  physical  examination  which  needs 
so  much  practice  as  percussion,  and  none  that  is  so  seldom  thor- 
oughly learned.  Many  physicians  never  succeed  in  acquiring  a 
facility  in  the  use  of  it  sufficient  to  make  them  rely  upon  their 
results.  Undoubtedly  one  of  the  greatest  difficulties  arises  from 
the  necessity  of  being  at  once  active  and  passive — at  once  the  per- 
cussor  and  the  one  who  listens  to  the  percussion.  Students  half 
unconsciously  get  to  treat  the  percussion  as  an  end  in  itself,  and 
hammer  away  industriously  without  realizing  that  two-thirds  of  the 
attention  must  be  given  to  listening,  while  the  percussion  itself 
should  become  semi-automatic. 

It  is  undoubtedly  an  advantage  to  possess  a  musical  ear,  but  this 
is  by  no  means  a  necessity.  Some  of  the  most  accurate  percussors 
that  I  know  possess  absolutely  no  musical  ear — no  ear,  that  is,  for 
pitch — and  form  their  judgments  in  percussing  upon  the  quality  or 
intensity  of  the  note,  and  upon  the  sense  of  resistance. 

In  this  country  practically  all  percussion  is  done  with  the  fin- 
gers ;  in  Germany  instruments  are  still  used  to  a  considerable  ex- 
tent. 

(a)  Mediate  and  Immediate  Percussion. 

Percussion  may  be  either  "  mediate  "  or  "  immediate, "  the  lat- 
ter term  referring  to  blows  struck  directly  upon  the  chest  with  the 
flat  of  the  hand,  or  upon  the  clavicles  with  the  tip  of  the  second 
finger. 


PERCUSSION. 


119 


(&)  Methods. 

Mediate  percussion  (which  is  used  ninety-nine  hundredths  of 
the  time)  is  performed  as  follows : 

The  patient  should  either  lie  down  or  sit  with  his  back  against 
some  support.  The  reason  of  this  is  that  for  good  percussion  one 


FIG.  73.— Position  of  the  Hands  When  Percussing  the  Right  Apex. 

needs  to  press  very  firmly  with  the  middle  finger  of  the  left  hand 
upon  the  surface  of  the  chest,  so  firmly  that  if  the  patient  is  sitting 
upon  a  stool  without  support  for  his  back,  it  will  need  considerable 
exertion  upon  his  part  to  avoid  losing  his  balance. 


120 


PHYSICAL  DIAGNOSIS. 


In  percussing  the  front  of  the  chest  it  is  important  to  have  the 
patient  sitting  or  lying  in  a  symmetrical  position— that  is,  without 
any  twist  or  tilting  to  one  side.  His  head  should  point  straight 
forward  and  h-is  muscles  must  be  thoroughly  relaxed.  Many  pa- 
tients, when  stripped  for  examination,  swell  out  their  chests  and 


Fm.  74.- Position  of  the  Hands  When  Percussing  the  Left  Apex. 

sit  up  with  a  military  erectness.  The  muscular  tension  thus  pro- 
duced modifies  the  percussion  note  and  causes  an  embarrassing 
multitude  of  muscle  sounds  which  greatly  disturb  auscultation. 

Having  placed  the  patient  in  an  easy  and  symmetrical  position, 
our  percussion  should  proceed  according  to  the  following  rules : 

(1)  Always  press  as  firmly  as  possible  upon  the  surface  of  the 


PERCUSSION. 


121 


chest  with  the  second  finger  of  the  left  hand '  on  the  dorsum  of 
which  the  blow  is  to  be  struck.  Kaise  the  other  fingers  of  the  left 
hand  from  the  chest  so  as  not  to  interfere  with  its  vibrations. 

(2)  Strike  a  quick,  perpendicular,  rebounding  blow  with  the  tip 
of  the  second  finger2  of  the  right  hand  upon  the  second  finger  of  the 
left  just  behind  the  nail,  imitating  as  far  as  possible  with  the  right 
hand  the  action  of  a  piano-hammer.  The  quicker  the  percussing 


FIG.  75.— The  Right  Way  to  Percuss— i.  e.<  From  the  Wrist. 

finger  gets  away  again  after  striking,  the  clearer  will  be  the  note 
obtained. 

(3)  Let  all  the  blows  struck  in  any  one  part  of  the  chest  be 
uniform  in  force. 

1  Left-handed  percussors  will,  of  course,  keep  the  right  hand  upon  the 
chest  and  strike  with  the  left. 

2  When  percussing  the  right  apex  I  prefer  to  strike  upon  the  thumb  (see 
Figs.  73  and  74)  as  it  is  almost  impossible  when  standing  directly  in  front 
of  the  patient  to  fit  any  of  the  fingers  comfortably  into  the  right  supraclavicular 
fossa. 


122 


PHYSICAL  DIAGNOSIS. 


(4)  Strike  from  the  wrist  and  not  from  the  elbow  (see  Figs.  75 
and  76).  The  wrist  must  be  held  perfectly  loose. 

(.5)  Keep  the  percussing  finger  bent  at  a  right  angle  as  in  Fig. 
77. 

The  force  to  be  used  in  percussion  depends  upon  the  purpose 


FIG.  76.— The  Wrong  Way  to  Percuss— i.  e..  From  the  Elbow. 

for  which  the  percussion  is  used — that  is,  upon  what  organ  we  are 
percussing — and  also  upon  the  thickness  of  the  muscles  covering 
that  part  of  the  chest.  For  example,  it  is  necessary  to  percuss 
very  strongly  when  examining  the  back  of  a  muscular  man,  where 
an  inch  or  two  of  muscle  intervenes  between  the  finger  on  which 


PERCUSSION. 


123 


we  strike  and  the  lung  from  which  we  desire  to  elicit  a  sound. 
Over  the  front  of  the  .chest  and  in  the  axillae  the  muscular  covering 
is  much  thinner,  and  hence  a  lighter  blow  suffices.  In  children  or 
emaciated  patients,  or  in  any  case  in  which  the  muscular  develop- 
ment is  slight,  percussion  should  be  as  light  as  is  sufficient  to  elicit  a 
clear  sound.  Heavy  percussion  is  sometimes  necessary  but  always 
unsatisfactory,  in  that  the  sound  which  it  elicits  conies  from  a  rela- 
tively large  area  of  the  chest  and  does  not  therefore  give  us  infor- 


FIG.  TT.— Proper  Position  of  the  Right  Hand  During  Percussion. 

mation  about  the  condition  of  any  sharply  localized  area.  If  a  car- 
penter, in  tapping  the  wall  to  find  the  position  of  the  studs,  strikes 
too  hard,  he  will  fail  to  find  the  beam,  because  the  blow  delivered 
over  the  spot  behind  which  the  beam  is  situated  is  so  forcible  as  to 
bring  out  the  resonance  of  the  hollow  parts  around.  It  is  the  same 
with  medical  percussion.  Heavy  percussion  is  always  inaccurate.1 
It  may  be  necessary  where  the  muscles  are  very  thick,  but  its  value 

1  See  also  below,  page  136,  the  lung  reflex. 


124 


PHYSICAL  DIAUJXO&IS. 


is  then  proportionately  diminished.  On  the  other  hand,  it  is  pos- 
sible to  strike  so  lightly  that  no  recognizable  sound  is  elicited  at 
all.  The  best  percussion,  therefore,  is  that  which  is  just  forcible 
enough  to  elicit  a  clear  sound  without  setting  a  large  area  of  chest 
wall  in  vibration. 

The  position  of  the  patient  above  described  applies  to  percus- 
sion of  the  front.     When  we  desire  to  percuss  the  back,  it  is  im- 


FIG.  78.-  Proper  Position  of  the  Patient  During  Percussion  of  the  Back. 

portant  to  get  the  scapulae  out  of  the  way  as  far  as  possible,  since 
we  cannot  get  an  accurate  idea  of  sounds  transmitted  through  them. 
To  accomplish  this,  we  put  the  patient  in  the  position  shown  in 
Fig.  78,  the  arms  crossed  upon  the  chest  and  each  hand  upon  the 
opposite  shoulder.  The  patient  should  be  made  to  bend  forward ; 
otherwise  the  left  hand  of  the  percussor  will  be  uncomfortably  bent 
backward  and  his  attention  thereby  distracted  (see  Fig.  79). 

When  the  axillae  are  to  be  percussed,  the  patient  should  put  the 
hands  upon  the  top  of  the  head. 


PERCUSSION. 


125 


(b)  Auscultatory  Percussion. 

If  while  percussing  one  auscults  at  the  same  time,  letting  the 
chest  piece  of  the  stethoscope  rest  upon  the  chest,  or  getting  the 
patient  or  an  assistant  to  hold  it  there,  the  sounds  produced  by- 
percussion  are  greatly  intensified,  and  changes  in  their  volume, 
pitch,  or  quality  are  very  readily  appreciated.  The  blows  must  be 


FIG.  79.  —Wrong  Position  for  Percussing  the  Back.    The  patient  should  be  bent  forward. 

very  lightly  struck,  either  upon  the  chest  itself  or  upon  the  finger 
used  as  a  pleximeter  in  the  ordinary  way.  Some  observers  use  a 
short  stroking  or  scratching  touch  upon  the  chest  itself  without 
employing  any  pleximeter. 

This  method  is  used  especially  in  attempting  to  map  out  the 
borders  of  the  heart  and  in  marking  the  outlines  of  the  stomach. 
In  the  hands  of  skilled  observers  it  often  yields  valuable  results, 


126 


PHYSICAL  DIAGNOSIS. 


but  one  source  of  error  must  be  especially  guarded  against.  The 
line  along  which  we  percuss,  when  approaching  an  organ  -whose  bor- 
ders we  desire  to  mark  out,  must  neither  approach  the  chest  piece  of 
the  stethoscope  nor  recede  from  it.  In  other  words,  the  line  along 
which  we  percuss  must  always  describe  a  segment  of  a  circle  whose 
centre  is  the  chest  piece  of  the  stethoscope  (see  Fig.  80).  If  we 
percuss,  as  we  ordinarily  do,  in  straight  lines  toward  or  away  from 
the  border  of  an  organ,  our  results  are  wholly  unreliable  since 
every  straight  line  must  bring  the  point  percussed  either  closer  to 


Percussion  arc. 


Chest-piece  of  - 
Stethoscope. 


Fia.  80.— Auscultatory  Percussion,  Showing  the  Arc  along  which  such  Percussion  should  be 

made. 

the  stethoscope  or  farther  from  it,  and  the  intensity  and  quality 
of  the  sounds  conducted  through  the  instrument  to  our  ears  vary 
directly  with  its  distance  from  the  point  percussed. 

It  will  be  readily  seen  that  the  usefulness  of  auscultatory  per- 
cussion is  limited  by  this  source  of  error,  and  that  considerable 
practice  is  necessary  before  one  can  get  the  best  results  from  this 
method.  Nevertheless  it  has,  I  believe,  a  place,  though  not  a  very 
important  one,  among  serviceable  methods  of  physical  examination 


PERCUSSION. 


127 


(c)  Palpatory  Percussion. 

Some  German  observers  use  a  method  of  percussion  in  which 
attention  is  fixed  directly  or  primarily  on  the  amount  of  resistance 
offered  by  the  tissues  over  which  percussion  is  made.  Even  in  or- 
dinary percussion  the  amount  of  resistance  is  always  noted  by 
experienced  percussors,  but  the  element  in  sound  is  usually  the 
main  object  of  attention.  Palpatory  percussion  is  rather  a  series 
of  short  pushes  against  various  points  on  the  chest  wall,  but  some 


Normal     dulness 

of  the  right  apex.     ~— • -^  _ 


Superficial  cardiac 
dulness. 


Liver  dulness. 


Liver  flatness. 


Trnube's  semilu- 
nar  tyinpanitic 
space. 


FIG.  81.— Percussion  Outlines  in  the  Normal  Chest. 

sound  is  elicited  and  probably  enters  into  the  rather  complex  judg- 
ment which  follows. 

In  this  country  palpatory  percussion  is  but  little  employed. 

II.  PERCUSSION  RESONANCE  OF  THE  NORMAL  CHEST. 

The  note  obtained  by  percussing  the  normal  chest  varies  a  great 
deal  in  different  areas.  In  Fig.  81,  the  parts  shaded  darkest  are 
those  that  normally  give  least  sound  when  percussed  in  the  manner 
described  above,  while  from  the  lightest  areas  the  loudest  and  clear- 
est sound  may  be  elicited. 


128 


PHYSICAL  DIAGNOSIS. 


_,-•    Upper  lobe. 


(___-  Splenic  area. 


(a)  The  sound  elicited  in  the  latter  areas  is  known  as  normal  or 
"vesicidar"  resonance,  and  is  due  to  the  presence  of  a  normal 
amount  of  air  in  the  vesicles  of  the  lung  underneath.  If  this  a.ir- 
containing  lung  is  replaced  by  a  fluid  or  solid  medium,  as  in  pleu- 
ritic effusion  or  pneumonia,  it  is  much  more  difficult  to  elicit  a 
sound,  and  such  sound  as  is  produced  is 
short,  high  pitched,  and  has  a  feeble  carry- 
ing power  when  compared  with  the  sound 
elicited  from  the  normal  lung.  This 
short,  feeble,  high-pitched  sound  is 
known  technically  as  a  "dull"  or 
„--  Lower  lobe,  "fiat "  sound,  flatness  designating 
the  extreme  of  the  qualities  that 
characterize  dulness.  Over  the 
parts  shaded  dark  in  Fig.  81,  we 
normally  get  a  dull  or  flat  tone,  the  darkest 
portions  being  flat  and  the  others  dull. 
The  heavy  shadow  on  the  right  corresponds 
to  the  position  occupied  by  the  liver,  or 
rather  by  that  part  of  it  which  is  in  imme- 
diate contact  with  the  chest  wall.  The  up- 
per portion  of  the  liver  is  overlapped  by  the 
right  lung  (see  Fig.  81),  and  hence  at  this 
point  we  get  a  certain  amount  of  resonance 
on  percussion,  although  the  tone  is  not  so 
clear  as  that  to  be  obtained  higher  up.  Be- 
low the  sixth  rib  we  find  true  flatness  near 
the  sternum  and  for  a  few  inches  to  the  right 
of  this  point.  As  we  go  toward  the  axilla, 

the  line  of  lung  resonance  slopes  down,  as  is  seen  in  Fig.  82.     Iii 
the  back  resonance  extends  to  the  ninth  or  tenth  ribs. 

Normal  Dull  Areas. 

(J)  On  the  left  side,  the  main  dull  area  corresponds  to  the  heart, 
which  at  this  point  approaches  the  chest  wall,  and  over  the  por- 
tion shaded  darkest  is  uncovered  by  the  lung.  The  part  here 


FIG.  S2.—  Position  of  the  Left 
Lung  in  the  Axilla. 


PERCUSSION.  129 

lightly  shaded  corresponds  to  that  portion  of  the  heart  which  is 
overlapped  by  the  margin  of  the  right  and  left  lungs. 

Over  the  portion  of  the  heart  not  overlapped  by  the  lung  (see 
Fig.  81,  p.  127)  the  percussion  note  is  nearly  flat  to  light  percus- 
sion, and  very  dull  even  when  strongly  percussed.  This  little 
quadrangular  area  is  known  as  the  "superficial  cardiac  space,"  and 
the  dulness  corresponding  to  it  is  referred  to  as  the  "  superficial " 
cardiac  dulness,  while  the  dulness  corresponding  to  the  outlines  of 
the  heart  itself  beneath  the  overlapping  lung  margins  is  called  the 
"  deep  "  cardiac  dulness. 

When  the  heart  becomes  enlarged,  both  of  these  areas,  the  deep 
and  the  superficial,  are  enlarged,  the  former  corresponding  to  the 
increased  size  of  the  heart  itself,  while  the  superficial  cardiac  space 
is  extended  because  the  margins  of  the  lungs  are  pushed  aside  and 
a  larger  piece  of  the  heart  wall  comes  in  contact  with  the  chest 
wall.  Accordingly,  either  the  superficial  or  the  deep  dulness  may 
be  mapped  out  as  a  means  of  estimating  the  size  of  the  heart. 
Each  method  has  its  advantages  and  its  advocates.  The  superficial 
dulness  is  easier  to  map  out,  but  varies  not  only  with  the  size  of  the 
heart,  but  with  the  degree  to  which  the  lungs  are  distended  with 
air,  or  adherent  to  the  pericardium  or  chest  wall.  What  we  are 
percussing  is  in  fact  the  borders  of  the  lungs  at  this  point. 

On  the  other  hand,  the  deep  cardiac  dulness  is  much  more  satis- 
factory as  a  means  of  estimating  the  size  of  the  heart  but  much 
more  difficult  to  map  out.  It  needs  a  trained  ear  and  long  practice 
to  percuss  out  correctly  the  borders  of  the  heart  itself,  especially 
the  right  and  the  upper  borders,  since  here  we  have  to  percuss 
over  the  sternum  where  differences  of  resonance  are  very  deceptive 
and  difficult  to  perceive. 

It  is  a  disputed  point  whether  light  or  forcible  percussion  should 
be  used  when  we  attempt  to  map  out  the  deep  cardiac  dulness. 
Heavy  percussion  is  believed  by  its  advocates  to  penetrate  through 
the  overlapping  lung  margins  and  bring  out  the  note  corresponding 
to  the  heart  beneath,  a  note  which,  they  say,  is  missed  altogether 
by  light  percussion.  On  the  other  hand,  those  who  employ  light 
percussion  contend  that  heavy  percussion  sets  in  vibration  so  large 
9 


130  PHYSICAL  DIAGNOSIS. 

an  area  of  lung  superficially  that  fine  distinctions  of  note  are  made 
impossible  (see  above,  p.  123). 

Good  observers  are  to  be  found  on  each  side  of  this  question, 
and  I  have  no  doubt  that  either  method  works  well  in  skilled 
hands.  Personally  I  have  found  light  percussion  preferable. 

Whatever  method  we  use  we  must  percuss  successive  points 
along  a  line  running  at  right  angles  to  the  border  of  the  organ 
which  we  wish  to  outline  until  a  change  of  note  is  perceived. 
Thus,  if  we  wish  to  percuss  out  the  upper  border  of  the  liver,  we 
strike  successive  points  along  a  line  running  parallel  to  the  ster- 
num and  about  an  inch  to  the  right  of  it. '  When  a  change  of  note 
is  perceived,  the  point  should  be  marked  with  a  skin  pencil ;  then 
we  percuss  along  a  line  parallel  to  the  first  one,  and  perhaps  an 
inch  farther  out,  and  again  mark  with  a  dot  the  point  at  which  the 
note  first  changes.  A  line  connecting  the  points  so  marked  upon 
the  skin  represents  the  border  of  the  organ  to  be  outlined. 

If  now  we  look  at  the  upper  part  of  the  chest  in  Fig.  81,  we 
notice  at  once  that  the  two  sides  are  not  shaded  alike :  the  left  apex 
is  distinctly  lighter  colored  than  the  right.  This  is  a  very  impor- 
tant point  and  one  not  sufficiently  appreciated  by  students.  The 
apex  of  the  normal  right  lung  is  distinctly  less  resonant  than  the 
apex  of  the  left  in  a  corresponding  position. 

In  percussing  at  the  bottom  of  the  left  axilla,  we  come  upon  a 
small  oval  area  of  dulness  corresponding  to  that  outlined  in  Fig.  82. 
This  is  the  area  of  splenic  dulness,  so  called,  and  corresponds  to 
that  portion  of  the  spleen  which  is  in  contact  with  the  chest  wall. 
This  dull  area  is  to  be  made  out  only  in  case  the  stomach  and  colon 
are  not  overdistended  with  air.  "When  these  organs  are  full  of  gas 
as  is  not  infrequently  the  case,  there  is  no  area  of  splenic  dulness 
and  the  whole  region  gives  forth,  when  percussed,  a  note  of  a  qual- 
ity next  to  be  described,  namely,  "  tympanitic. " 

(c)  Tympanitic  resonance  is  that  obtained  over  a  hollow  body, 
like  the  stomach  when  moderately  distended  with  air.4  It  is  usu- 

1  Or  we  may  reverse  the  procedure  ;  percuss  first  over  the  liver  and  then 
work  toward  the  lung  above  until  the  note  becomes  more  resonant. 

2  Extreme  distention  here,  as  in  a  snare  drum,  is  associated  with  a  dulj 
percussion  note  (see  below,  p.  332). 


PERCUSSION.  131 

ally  of  a  higher  pitch  than  the  resonance  to  be  obtained  over  the 
normal  lung,  and  may  be  elicited  by  percussion  lighter  than  that 
needed  to  bring  out  the  lung  resonance.  It  differs  also  from  the 
vesicular  or  pulmonary  resonance  in  quality,  in  a  way  easy  to  appre- 
ciate but  difficult  to  describe.  Tympanitic  resonance  is  usually  to 
be  heard  when  one  percusses  over  the  front  of  the  left  chest  near 
the  ensiform  cartilage  and  for  a  few  inches  to  the  left  of  this  point 
over  an  area  corresponding  with  that  of  the  stomach  more  or  less 
distended  with  air.  This  tyinpanitic  area,  known  as  "  Traube's 
semilunar  space,"  varies  a  great  deal  in  size  according  to  the  contents 
of  the  stomach.  It  is  bounded  on  the  right  by  the  liver  flatness, 
above  by  the  pulmonary  resonance,  on  the  left  by  the  splenic  dul- 
ness,  and  below  by  the  resonance  of  the  intestine,  which  is  also 
tyinpanitic,  although  its  pitch  is  different  owing  to  the  different 
size  and  shape  of  the  intestine. 

(The  right  axilla  shows  normal  lung  resonance  down  to  the 
point  at  which  the  liver  flatness  begins,  as  shown  in  Fig.  81.) 

In  the  back,  when  the  scapulae  are  drawn  forward,  as  shown  in 
Fig.  78,  page  124,  percussion  elicits  a  clear  vesicular  resonance  from 
top  to  bottom  on  each  side,  although  the  top  of  the  right  lung  is  al- 
ways slightly  less  resonant  than  the  top  of  the  left,  and  sometimes  the 
bottom  of  the  right  lung  is  slightly  less  resonant  than  the  corre- 
sponding portion  of  the  left,  on  account  of  the  presence  of  the  liver 
on  the  right. 

It  should  be  remembered,  however,  that  in  the  majority  of  cases 
the  resonance  throughout  the  back  is  distinctly  less  than  that  ob- 
tained over  the  front,  on  account  of  the  greater  thickness  of  the 
back  muscles.  Yet  in  children  or  emaciated  persons,  or  where  the 
muscular  development  is  slight,  there  may  be  as  much  resonance 
behind  as  in  front. 

Importance  of  Percussing  Symmetrical  Points. — Since  we  depend 
for  our  standard  of  resonance  upon  comparison  with  a  similar  spot 
on  the  outside  of  the  chest,  it  is  all-important  that  in  making  such 
comparisons  we  should  percuss  symmetrical  points,  and  not,  for 
example,  compare  the  resonance  over  the  third  rib  in  the  right  front 
with  that  over  the  third  interspace  on  the  left,  since  more  resonance 
can  always  be  elicited  over  an  interspace  than  over  a  rib.  This 


132  PHYSICAL  DIAGNOSIS. 

comparison  of  symmetrical  points,  however,  is  interfered  with  by 
the  presence  of  the  heart  on  one  side  and  the  liver  on  the  other,  as 
well  as  by  the  fact  that  the  apex  of  the  right  lung  is  normally  less 
resonant  than  that  of  the  left.  A  resonance  which  would  be  patho- 
logically feeble  if  obtained  over  the  left  top  may  be  normal  over  the 
right.  Where  both  sides  are  abnormal,  as  in  bilateral  disease  of 
the  lung,  or  where  fluid  accumulates  in  both  pleural  cavities,  we 
have  to  make  the  best  comparison  we  can  between  the  sound  in  the 
given  case  and  an  ideal  standard  carried  in  the  mind. 

It  must  always  be  remembered  that  the  amount  of  resonance 
obtained  at  any  point  by  percussion  depends  upon  how  hard  one 
strikes,  as  well  as  upon  the  conditions  obtaining  within  the  chest. 
A  powerful  blow  over  a  diseased  lung  may  bring  out  more  reso- 
nance than  a  lighter  blow  over  a  normal  lung.  To  strike  with  per- 
fect fairness  and  with  equal  force  upon  each  side  can  be  learned  only 
by  considerable  practice.  Furthermore,  the  distance  from  the  ear 
to  each  of  the  two  points,  the  resonance  of  which  we  are  compar- 
ing, must  be  the  same — that  is,  we  must  stand  squarely  in  front  or 
squarely  behind  the  patient,  otherwise  the  note  coming  from  the 
part  farther  from  the  ear  will  sound  duller  than  that  coming  from 
the  nearer  side. 

The  normal  resonance  of  the  different  parts  of  the  chest  can  be 
considerably  modified  by  the  position  of  the  patient,  by  deep  breath- 
ing, by  muscular  exertion,  and  by  other  less  important  conditions. 
If,  for  example,  the  patient  lies  upon  the  left  side,  the  heart  swings 
out  toward  the  left  axilla  and  its  dulness  is  extended  in  the  same 
direction.  Deep  inspiration  pushes  forward  the  margins  of  the 
lungs  so  that  they  encroach  upon  and  reduce  the  area  of  the  heart 
dulness  and  liver  dulness  After  muscular  exertion  the  lungs  be- 
come more  than  ordinarily  voluminous,  owing  to  the  temporary  dis- 
tention  brought  about  by  the  unusual  amount  of  work  thrown  upon 
them. 

The  area  of  cardiac  dulness  is  increased  in  any  condition  involv- 
ing insufficient  lung  expansion.  Thus,  in  children,  in  debility, 
chlorosis,  or  fevers,  the  space  occupied  by  the  lungs  is  relatively" 
small  and  the  dull  areas  corresponding  to  the  heart  and  liver  are 


PERCUSSION.  133 

proportionately  enlarged.  In  old  age,  on  the  other  hand,  when  the 
lungs  have  lost  part  of  their  elasticity  and  sag  down  over  the  heart 
and  liver,  the  percussion  dulness  of  these  organs  is  reduced. 

Conditions  Modifying  the  Percussion  Note  in  Health. — The  de- 
velopment of  muscle  or  fat  as  well  as  the  thickness  of  the  chest 
wall  will  influence  greatly  the  amount  of  resonance  to  be  obtained 
by  percussion.  Indeed,  we  see  now  and  then  an  individual  in  no 
part  of  whose  chest  can  any  clear  percussion  tone  be  elicited.  In 
women,  the  amount  of  development  of  the  breasts  has  also  great 
influence  upon  the  percussion  note  In  children,  the  note  is  gener- 
ally clearer,  and  only  the  lightest  percussion  is  to  be  used  on  ac- 
count of  the  thinness  of  the  chest  wall.  In  old  people  whose  lungs 
are  almost  always  more  or  less  emphysematous,  a  shade  of  tym- 
panitic  quality  is  added  to  the  normal  vesicular  resonance.  The 
distention  of  the  colon  with  gas  may  obliterate  the  liver  dulness  by 
rotating  that  organ  so  that  only  its  edge  is  in  contact  with  the  chest 
wall,  and  if  there  is  wind  in  the  stomach,  a  variable  amount  of 
tympany  is  heard  on  percussing  the  lower  left  front  and  axilla  or 
even  in  the  left  back. 

If  a  patient  is  examined  while  lying  on  the  side  the  amount  of 
resonance  over  the  lung  corresponding  to  the  side  on  which  he 
lies  is  usually  less  than  that  of  the  side  which  is  uppermost,  because 
there  is  more  air  in  the  latter.1  Whatever  the  patient's  position, 
the  amount  of  resonance  is  also  greater  at  the  end  of  inspiration 
than  at  the  end  of  expiration,  for  the  reason  just  given.  As  the 
kings  expand  with  full  inspiration,  their  borders  move  so  as  to 
cover  a  larger  portion  of  the  organs  which  they  normally  overlap. 
Portions  of  the  chest  which  at  the  end  of  expiration  are  dull  or 
flat,  owing  to  the  close  juxtaposition  of  the  heart,  liver,  or  spleen, 
become  resonant  at  the  end  of  inspiration  For  example,  the  lower 
margin  of  the  right  lung  moves  down  during  inspiration  so  as  to 
cover  a  considerably  larger  portion  of  the  liver 

Percussion  as  a  Means  of  Ascertaining  the  Movability  of  the  Lung 
Borders. — It  is  often  of  great  importance  to  determine  not  merely 

1  There  is  also  a  shade  of  tympany  associated  with  the  dulness  of  the 
feebly  expanded  lung  of  the  lower  side. 


134  PHYSICAL  DIAGNOSIS. 

the  position  of  the  resting  lung  but  its  power  to  expand  freely. 
This  can  be  ascertained  by  percussion  in  the  following  way :  The 
lower  border  of  the  lung  resonance,  say  in  the  axilla,  is  carefully 
marked  out.  Then  percussion  is  made  over  a  point  just  below  the 
level  of  the  resting  lung  and  at  the  same  time  the  patient  is  directed 
to  inspire  deeply  If  the  lung  expands  and  its  border  moves  down, 
the  percussion  note  will  change  suddenly  from  dull  to  resonant 
during  the  inspiration.  An  excursion  of  two  or  three  inches  can 
often  be  demonstrated  by  this  method,  which  is  especially  impor- 
tant for  the  anterior  and  posterior  margins  of  the  lung.  In  the 
axilla  Litten's  phrenic  shadow  will  give  us  the  same  information. 

The  mobility  of  the  borders  of  the  lung,  as  determined  by  this 
method,  is  of  considerable  clinical  importance,  for  an  absence  of 
such  mobility  may  indicate  pleuritic  adhesions.  Its  amount  de- 
pends upon  various  conditions  and  varies  much  in  different  indi- 
viduals, but  complete  absence  of  mobility  is  always  pathological. 

(d)  Cracked-Pot  Resonance 

When  percussing  the  chest  of  a  crying  child,  we  sometimes 
notice  that  the  sound  elicited  has  a  peculiar  "  chinking "  quality, 
like  that  produced  by  striking  one  coin  with  another,  but  more 
muffled.  The  sound  may  be  more  closely  imitated,  and  the  mode 
of  its  production  illustrated,  by  clasping  the  hands  palm  to  palm 
so  as  to  enclose  an  air  space  which  communicates  with  the  outer  air 
through  a  chink  left  open,  and  then  striking  the  back  of  the  under 
hand  against  the  knee  By  the  blow,  air  is  forced  out  through  the 
chink  with  a  sound  like  that  of  metallic  coins  struck  together. 

In  disease,  the  cracked-pot  sound  is  usually  produced  over  "a 
pulmonary  cavity  (as  in  advanced  phthisis)  from  which  the  air  is 
suddenly  and  forcibly  expelled  by  the  percussion  stroke. 

It  is  much  easier  to  hear  this  peculiar  sound  if,  while  percuss- 
ing, one  listens  with  a  stethoscope  at  the  patient's  open  mouth. 
The  patient  himself  holds  the  chest  piece  of  the  instrument  just  in 
front  of  his  open  mouth,  leaving  the  auscultator's  hands  free  foi 
percussing. 


PERCUSSION.  135 

(e)  Amphoric  Resonance. 

A  low-pitched  hollow  sound  approximating  in  quality  to  tyin- 
panitic  resonance,  and  sometimes  obtained  over  pulmonary  cavities 
or  over  pneumothorax,  has  received  the  name  of  amphoric  reso- 
nance It  may  be  imitated  by  percussing  the  trachea  or  the  cheek 
when  moderately  distended  with  air. 

Summary 

The  varieties  of  resonance  to  be  obtained  by  percussing  the  nor- 
mal thorax  are : 

(1)  Vesicular  resonance,  to  be  obtained  over  normal  lung  tissue. 

(2)  Tympanitic  resonance,  to  be  obtained  in  Traube's  semilunar 
space 

(3)  Diminished  resonance  or  dulness,  such  as  is  present  over  the 
scapulae,  and 

(4)  Absence  of  resonance  or  flatness,  such  as  is  discovered  when 
we  percuss  over  the  lowest  ribs  in  the  right  front 

(5)  Cracked-pot  resonance,  sometimes  obtainable  over  the  chest 
of  a  crying  child. 

(6)  Amphoric  resonance,  obtainable  over  the  trachea. 

Any  of  these  sounds  may  denote  disease  if  obtained  in  portions 
of  the  chest  where  they  are  not  normally  found.  Each  has  its 
place,  and  becomes  pathological  if  found  elsewhere  Tympanitic  reso- 
nance is  normal  at  the  bottom  of  the  left  front  and  axilla,  but  not 
elsewhere.  Dulness  or  flatness  is  normal  over  the  areas  corre- 
sponding to  the  heart,  liver,  and  spleen,  and  over  the  scapulae,  but 
not  elsewhere  unless  the  muscular  covering  of  the  chest  is  enor- 
mously thick.  Vesicular  resonance  is  normal  over  the  areas  corre- 
sponding to  the  lungs,  but  becomes  evidence  of  disease  if  found 
over  the  cardiac  or  hepatic  areas. 

Cracked-pot  resonance  may  be  normal  if  produced  while  per- 
cussing the  chest  of  a  child,  but  under  all  other  conditions,  so  far 
as  is  known,  denotes  disease. 

Amphoric  resonance  always  means  disease,  usually  pulmonary 
cavity  or  pneumothorax,  if  found  elsewhere  than  over  the  trachea. 


136  PHYSICAL  DIAGNOSIS.  , 

(/) '  The  Lung  Reflex. 

It  must  also  be  remembered,  when  percussing,  that  in  some  cases 
every  forcible  percussion  blow  increases  the  resonance  to  be  ob- 
tained by  subsequent  blows.  Any  one  who  has  demonstrated  an 
area  of  percussion  dulness  to  many  students  in  succession  must 
have  noticed  occasionally  that  the  more  we  percuss  the  dull  area, 
the  more  resonant  it  becomes,  so  that  to  those  who  last  listen  to 
the  demonstration  the  difference  which  we  wish  to  bring  out  is  much 
less  obvious  than  to  those  who  heard  the  earliest  percussion  strokes. 
Abrams  has  referred  to  this  fact  under  the  name  of  the  "lung  re- 
flex," believing,  partly  on  the  evidence  of  fluoroscopic  examination, 
that  if  an  irritant  such  as  cold  or  mustard  is  applied  to  any  part  of 
the  skin  covering  the  thorax,  the  lung  expands  so  that  a  localized 
temporary  emphysema  is  produced  in  response  to  the  irritation. 
Apparently  percussion  has  a  similar  effect. 

III.   SENSE  OF  RESISTANCE. 

While  percussing  the  chest  we  must  be  on  the  lookout  not  only 
for  changes  in  resonance,  but  for  variations  in  the  amount  of  resist- 
ance felt  underneath  the  finger.  Normally  the  elasticity  of  the 
chest  walls  over  the  upper  fronts  is  considerably  greater  and  the 
sense  of  resistance  considerably  less  than  that  felt  over  the  liver. 
In  the  axillae  and  over  those  portions  of  the  back  not  covered  by 
the  scapulae,  we  feel  in  normal  chests  an  elastic  resistance  when 
percussing  which  is  in  contrast  with  the  dead,  woodeny  feeling 
which  is  communicated  to  the  finger  when  the  air-containing  lung 
is  replaced  by  fluid  or  solid  contents  (pleuritic  effusion,  pneu- 
monia, phthisis,  etc.).  In  some  physicians  this  sense  of  resistance 
is  very  highly  developed  and  as  much  information  is  obtained 
thereby  as  through  the  sounds  elicited.  As  a  rule,  however,  it  is 
only  by  long  practice  that  the  sense  of  resistance  is  cultivated  to  a 
point  where  it  becomes  of  distinct  use  in  diagnosis. 


CHAPTER   VII. 

AUSCULTATION 

AUSCULTATION  may  be  practised  by  placing  one's  ear  directly 
against  the  patient's  chest  (immediate  auscultation)  or  with  the 
help  of  a  stethoscope  (mediate  auscultation). 

Each  method  has  its  place.  Immediate  auscultation  is  said  to 
have  advantages  similar  to  those  of  the  low  power  of  the  micro- 
scope, in  that  it  gives  us  a  general  idea  of  the  condition  of  a  rela- 
tively large  area  of  tissue,  while  the  stethoscope  may  be  used,  like 
the  oil  immersion  lens,  to  bring  out  details  at  one  or  another  point 

On  the  other  hand,  I  am  firmly  convinced  that  the  unaided  ear 
can  perceive  sounds  conducted  from  the  interior  of  the  lung — sounds 
quite  inaudible  with  any  stethoscope — and  that  in  this  way  the 
faint  tubular  breathing  produced  by  deep-seated  areas  of  solidified 
lung  may  be  recognized. 

Immediate  auscultation  may  be  objected  to 

(a)  On  grounds  of  delicacy  (when  examining  persons  of  the 
opposite  sex). 

(1}  On  grounds  of  cleanliness  (although  the  chest  may  be  cov- 
ered with  a  towel  so  as  to  protect  the  auscultator  to  a  certain 
extent). 

(c)  Because  we  cannot  conveniently  reach  the  supraclavicular 
or  the  upper  axillary  regions  in  this  way. 

(d)  Because  it  is  difficult  to  localize  the  different  valvular  areas 
and  the  sites  of  cardiac  murmurs  if  immediate  auscultation  is  em- 
ployed. 

On  account  of  the  latter  objection  the  great  majority  of  observ- 
ers now  use  the  stethoscope  to  examine  the  heart.  For  the  lungs, 
both  methods  are  employed  by  most  experienced  auscultators. 
I  have  already  mentioned  the  importance  of  immediate  auscul- 
tation in  the  search  for  deep-seated  areas  of  pneumonia.  Atten- 


138  PHYSICAL  DIAGNOSIS. 

tion  has  also  been -called  by  Conner  (Assoc.  of  American  Physicians, 
1907,  p.  113)  to  the  fact  that  the  diastolic  murmur  of  aortic  insuf- 
ficiency is  sometimes  audible  to  the  unaided  ear  when  it  cannot  be 
heard  with  any  form  of  stethoscope.  Faint,  high-pitched  blowing 
sounds  are  those  which  the  free  ear  is  especially  adapted  to  detect. 
This  is  doubtless  due,  as  Conner  explains,  to  the  fact  that  the 
tubes  of  the  stethoscope  do  not  conduct  high-pitched  sounds  well. 
With  the  free  ear  we  have  also  the  opportunity  to  detect  the  bone- 
conducted  sounds  which  are  missed  in  mediate  stethoscopic  auscul- 
tation. 

MEDIATE  AUSCULTATION. 

1.   Selection  of  a  Stethoscope. 

(1)  It  is  as  rash  for  any  one  to  select  a  stethoscope  without  first 
trying  the  fit  of  the  ear  pieces  in  his  ears  as  it  would  be  to  buy  a 
new  hat  without  trying  it  on.     What  suits  A.  very  well  is  quite  im- 
possible for  B.     It  is  true  that  one  can  get  used  to  almost  any 
stethoscope  as  one  can  to  almost  any  hat,  but  it  is  not  necessary  to 
do  so.     The  ear  pieces  of  the  ordinary  stethoscope  are  often  too 
small  and  rarely  too  large.     In  case  of  doubt,  therefore,  it  is  better 
to  err  upon  the  side  of  getting  a  stethoscope  with  too  large  rather 
than  too  small  ends. 

(2)  The  binaural  stethoscope,  which  is  now  almost  exclusively 
used  in  this  country,  maintains  its  position  in  the  ears  of  the  aus- 
cultator  either  through  the  pressure  of  a  rubber  strap  stretched 
around  the  metal  tubes  leading  to  the  ears,  or  by  means  of  a  steel 
spring  connecting  the  tubes.     Either  variety  is  usually  satisfactory, 
but  I  prefer  a  stethoscope  made  with  a  steel  spring  (see  Fig.  83) 
because  such  a  spring  is  far  less  likely  to  break  or  lose  its  elasticity 
than  a  rubber  strap.     A  rubber  strap  can  always  be  added  if  this 
is  desirable.     It  is  important  to  pick  out  an  instrument  possessing 
a  spring  not  strong  enough  to  cause  pain  in  the  external  meatus  of 
the  ear  and  yet  strong  enough  to  hold  the  ear  pieces  firmly  in  place. 
Persons  with  narrow  heads  need  a  much  more  powerful  spring  or 
strap  than  would  be  convenient  for  persons  with  wide  heads. 


AUSCULTATION. 


139 


(3)  The  rubber  tubing  used  to  join  the  metallic  tubes  to  the 
chest  piece  of  the  instrument  should  be  as  flexible  as  possible  (see 
Fig.  83).  Stiff  tubing  (see 
Fig.  84)  makes  it  necessary 
for  the  auscultator  to  move 
his  head  and  body  from 
place  to  place  as  the  exam- 
ination of  the  chest  pro- 
gresses, while  if  flexible 
tubing  is  used  the  head  need 
seldom  be  moved  and  a  great 
deal  of  time  and  fatigue  is 
thus  saved.  Stiff  stetho- 
scopes are  especially  incon- 
venient when  examining  the 
axilla. 

(4)  Jointed  stethoscopes 
which  fold  up  or  take  apart 
should    be     scrupulously 
avoided.     They  are  a  delu- 
sion   and    a  snare,  apt    to 
come  apart  at  critical  mo- 
ments, and  to  snap  and  creak 
at  the  joints  when  in  use, 

sometimes  producing  in  this  way  sounds  which 
may  be  easily  mistaken  for  rales.  Such  an  in- 
strument is  no  more  portable  nor  compact  than 
the  ordinary  form  with  flexible  tubes.  It  has, 
therefore,  no  advantages  over  stethoscopes  made 
in  one  piece  and  possesses  disadvantages  which 
are  peculiarly  annoying. 

(5)  The  Chest  Piece. — The  majority  of  the 
stethoscopes  now  in  use  have  a  chest  piece  of 

hard-rubber  or  wood  with  a  diameter  of  about  seven-eighths  of  an 
inch.  Chest  pieces  of  larger  diameter  than  this  are  to  be  avoided 
as  they  are  very  difficult  to  maintain  in  close  apposition  with  thin 


FIG.  84.  — Camman 
Stethoscope  With  Stiff 
Tubing  and  Rubber 
Strap. 


FIG.  83.  —  Stethoscope 
Fitted  With  Long 
Flexible  Tubes,  Espe- 
cially Useful  When 
Examining  Children. 


140 


PHYSICAL  DIAGNOSIS. 


chests.     To  avoid  this  difficulty  the  chest  piece  is  sometimes  made 
of  soft-rubber  or  its  diameter  still  further  reduced. 

(6)  The  Bowles  Stethoscope.— (See  Figs.  85  and  86).  Within 
recent  years  there  has  been  introduced  an  instrument  which,  for 
many  purposes,  seems  to  me  far  superior  to  any  other  form  of  stetho- 
scope with  which  I  am  acquainted.  Its  pe- 
culiarity is  the  chest  piece, 
which  consists  of  a  very  shal- 
low steel  cup  (see  Fig.  87) 
over  the  mouth  of  which  a 
thin  metal  plate  or  a  bit 
of  pigskin  is  fastened.  The 
metal  or  pigskin  diaphragm 
serves  simply  to  prevent  the 
tissues  of  the  chest  from  pro- 
jecting into  the  shallow  cup 
of  the  chest  piece  when  the 
latter  is  pressed  against  the 
chest,  -and  does  not  in  any 
other  way  contribute  to  the 
sounds  which  we  hear  with 
the  instrument.  This  is 
proved  by  the  fact  that  we 
can  hear  as  well  even  when 
the  diaphragm  is  cracked 
across  in  several  directions. 
With  this  instrument  al- 
most all  sounds  produced 
within  the  chest  can  be  heard 

FI«».  85.-Bowies'  stetho-much  more  distinctly  than  in 
scope.   Front  view,     any  other  variety  of  stetho- 
scope.      Cardiac     murmurs 
which   are    inaudible   with  any  other  stetho- 
scope may  be  distinctly  heard  with  this.    Espe- 
cially is   this  true   of   low-pitched    murmurs 
due    to    aortic    re  gurgitation.      Yet  it  is  useful   for   examination 
not  merely  of  the  heart,  but  of  the  lungs  as  well.      For  any  one 


FIG.  86.— Combination 
Bowies'  Stethoscope. 


AUSCULTATION. 


141 


who  has  difficulty  in  hearing  the  ordinary  cardiac  or  respiratory 
sounds,  or  for  one  who  is  partially  deaf,  the  instrument  is  invalu- 
able. As  the  metal  rim  of  the  chest  is  apt  to  get  unpleasantly 
cold,  it  is  best  to  cover  it  with  a  bit  of  rubber  or  kid.  This  saves 
the  patient  some  discomfort  and  also  tends  to  prevent  the  instru- 
ment from  slipping  on  the  skin.  The  flat  chest  piece  makes  the 
instmment  very  useful  in  listening  to  the  posterior  portions  of  the 
lungs  in  cases  of  pneumonia  in  which  the  patient  is  too  sick  to  be 
turned  over  or  to  sit  up.  Without  moving  the  patient  at  all  we  can 


FIG.  87.— Chest  Piece  of  Bowles*  Stethoscope.  On  the  right  the  shallow  cup  communicating 
with  the  ear  tubes.  On  the  left  the  diaphragm  which  covers  the  cup,  and  the  ring  which 
holds  it  in  place. 

work  the  chest  piece  in  under  the  back  of  the  patient  by  pressing 
down  the  bed-clothes,  and  in  this  way  can  listen  to  any  part  of 
the  chest  without  moving  the  patient.  A  further  advantage  of 
the  instrument  is  that  it  enables  us  to  gain  an  approximately  ac- 
curate idea  of  the  heart  sounds  without  undressing  the  patient.  Re- 
spiratory sounds  cannot  well  be  listened  to  through  the  clothes, 
as  the  rubbing  of  the  latter  may  simulate  rales. 

There  are  two  purposes  for  which  I  have  found  the  Bowles 
stethoscope  inferior  to  the  ordinary  stethoscope : 

(1)  For  listening  over  the  apex  of  the  lung  for  fine  rales,  e.g.,  in 
incipient  phthisis. 

(2)  For  listening  for  superficial  sounds,  such  as  a  friction  rub  or- 


142 


PHYSICAL  DIAGNOSIS. 


a  presystolic  murmur. '  When  I  desire  to  listen  for  fine  rales  at 
an  apex,  for  a  friction  rub,  or  for  a  presystolic  murmur,  I  separate 
the  chest  piece  of  the  Bowles  stethoscope  from  the  hard-rubber 
bell  into  which  it  is  inserted,  thereby  converting  the  instrument 
into  one  of  the  ordinary  form.  With  an  extra  hard-rubber  bell 

attached,  the  instrument  is 
no  more  bulky  than  an 
ordinary  stethoscope,  and 
far  more  efficient.  When 
used  for  listening  to  the 
respiration,  the  Bowles  in- 
strument gives  us  informa- 
tion similar  in  some  re- 
spects to  that  obtained  by 
the  use  of  the  free  ear — 
that  is,  we  are  through  it 
enabled  to  ascertain  by  lis- 
tening at  one  spot  the  con- 
dition of  a  much  larger 
area  of  the  chest  than  can 
in  any  other  way  be  inves- 
tigated. 

Owing  to  the  fact  that 
both  cardiac  and  respiratory 
sounds  are  magnified  by  the 
Bowles  stethoscope,  this 
instrument  is  especially  well 
adapted  for  use  with  some 

sort  of  an  attachment  whereby  several  sets  of  ear  pieces  are  so 
joined  by  tubing  to  one  chest  piece  that  several  persons  may  listen 
at  once.  Bowies'  multiple  stethoscope,  fitted  for  six  and  for  twelve 
observers,  is  seen  in  Figs.  88  and  89,  and  the  method  of  its  use  in 

1  It  has  frequently  been  observed,  when  listening  with  the  ordinary  stetho- 
scope, that  a  presystolic  murmur  can  be  better  heard  if  only  the  very  lightest 
pressure  is  made  with  the  stethoscope.  The  fact  that  a  thrill  is  communicated 
to  the  chest  wall,  and  that  that  thrill  is  connected  with  the  audible  murmur 
explains  my  calling  this  murmur  a  superficial  one. 


FIG.  88.-  Bowies'  Multiple  Stethoscope  for  Six  Stu- 
dents. 


AUSCULTATION. 


143 


Fig.  90.  la  the  teaching  of  auscultation  this  instrument  is  of  great 
value,  saving  as  it  does  the  time  of  the  instructor  and  of  the  stu- 
dents and  the  strength  of  the  patient.  The  sounds  conducted 
through  any  one  of  the  twelve  tubes  used  in  this  instrument  are 
as  loud  as  those  to 
be  heard  with  a 
single  instrument  of 
the  ordinary  form, 
although  far  fainter 
than  those  to  be 
heard  with  a  single 
Bowles  stethoscope. 

II.    The  Use  of  the 
Stethoscope. 

Having  secured 
an  instrument 
which  fits  the  ears 
satisfactorily,  the 
beginner  may  get  a 
good  deal  of  prac- 
tice by  using  it  up- 
on himself,  especi- 
ally upon  his  own 
I  ,  ,,,,  ,  •  ,.  PIG.  89.— Bowies'  Multiple  Stethoscope  for  Twelve  Studqats. 

point  to  be  learned  is  to  disregard  various  irrelevant  sounds  and  to 
concentrate  attention  upon  those  which  are  relevant.  Almost  any 
one  hears  enough  with  a  stethoscope,  and  most  beginners  hear  too 
much.  No  great  keenness  of  hearing  is  required,  for  the  sounds 
which  we  listen  for  are  not,  as  a  rule,  difficult  to  hear  if  attention 
is  concentrated  upon  them. 

A.   Selective  Attention  and   What  to  Disregard. 

Accordingly,  the  art  of  using  a  stethoscope  successfully  depends 
iipon  the  acquisition  of  two  powers — 

(«)  A  knowledge  of  what  to  disregard.      (&)  A  selective  atten- 


144 


PHYSICAL  DIAGNOSIS. 


tion  or  concentration  upon  those  sounds  which  we  know  to  be  of 
importance. 

Among  the  sounds  which  we  must  learn  to  disregard  are  the 
following : 

(1)  Noises  produced  in  the  room  or  its  immediate  neighborhood, 
but  not  connected  with  the  patient  himself.  It  is,  of  course,  easier 


Fiu.  90.— Bowies'  Multiple  Stethoscope  in  Use.    Twelve  students  listening  at  once 

to  listen  in  a  perfectly  quiet  room  where  there  are  no  external 
noises  which  need  to  be  excluded  from  attention,  but  as  the  greater 
part  of  the  student's  work  must  be  done  in  more  or  less  noisy 
places,  it  is  for  the  beginner  a  practial  necessity  to  learn  to  with- 
draw his  attention  from  the  various  sounds  which  reach  his  ear 
from  the  street,  from  other  parts  of  the  building,  or  from  the  room 


AUSCULTATION.  145 

in  which  he  is  working.     This  is  at  first  no  easy  matter,  but  can 
be  accomplished  with  practice. 

(2)  When  the  power  to  disregard  external  noises  has  been  ac- 
quired, a  still  further  selection  must  be  made  among  the  sounds 
which  come  to  the  ear  through  the  tubes  of  the  stethoscope.    Noises 
produced  by  friction  of  the  chest  piece  of  the  stethoscope  upon  the 
skin  are  especially  deceptive  and  may  closely  simulate  a  pleural  or 
pericardial  friction  sound.     It  is  well  for  the  student  to  experiment 
upon  the  nature  and ,  extent  of  such  "  skin  rubs  "  by  deliberately 
moving  the  chest  piece  of  the  stethoscope  upon  the  skin  and  listen- 
ing to  the  sounds  so  produced.     Mistakes  can  be  avoided  in  the 
majority  of  cases  by  holding  the  chest  piece  of  the  stethoscope  very 
firmly  against  the  chest.     This  can  be  easily  done  when  the  patient 
is  in  the  recumbent  position,  but  when  the  patient  is  sitting  up  it 
may  be  necessary  to  press  so  hard  with  the  chest  piece  of  the 
stethoscope  as  to  throw  the  patient  off  his  balance  unless  he  is  in 
some  way  supported ;  accordingly,  it  is  my  practice  in  many  cases 
to  put  the  left  arm  around  and  behind  the  patient  so  as  to  form  a 
support,  against  which  he  can  lean  when  the  chest  piece  of  the 
stethoscope  is  pressed  strongly  against  his  chest.     When  listening 
to  the  back  of  the  chest,  the  manoeuvre  is  reversed.     If  the  skin 
is  very  dry,  the  ribs  are  very  prominent,   or  the  chest  is  thickly 
covered  with   hair,  it  may  be  impossible   to   prevent   the   occur- 
rence of   adventitious  sounds    due  to  friction  of  the  chest  piece 
upon  the  chest,  no  matter  how  firmly  the  instrument  is  held.     In 
case  of  doubt,  and  in  any  case  in  which  a  diagnosis  of  pleural  or 
pericardial  friction  is  in  question,  the  surface  of  the  chest,  at  the 
point  where  we  desire  to  listen,  should  be  moistened  and  any  hair 
that  may  be  present  thoroughly  wetted  with  a  sponge,  so  that  it 
will  lie  flat  upon  the  chest.     Otherwise  the  friction  of  the  hair 
under  the  chest  piece  of  the  stethoscope  may  simulate  crepitant 
rales  as  closely  as  "  skin  rubs  "  simulate  pleural  friction. 

(3)  The  friction  of  the  fingers  of  the  auscultator  upon  the  chest 
piece  or  on  some  other  part  of  the  stethoscope  frequently  gives  rise 
to  sounds  closely  resembling  rales  of  one  or  another  description. 
The  nature\of  these  sounds  can  be  easily  learned  by  intentionally 
moving  the  fingers  upon  the  stethoscope.     They  are  to  be  avoided 

10 


146  PHYSICAL  DIAGNOSIS. 

by  wetting  the  fingers,  grasping  the  bell  firmly,  and  by  touching  it 
with  as  few  fingers  as  will  suffice  to  hold  it  close  against  the  chest. 

(4)  Noises  produced  by  a  shifting  of  the  parts  of  the  stetho- 
scope upon  each  other  are  especially  frequent  in  stethoscopes  made 
in  several  pieces  and  jointed  together.      A  variety  of  snapping  and 
cracking  sounds,  not  at  all  unlike  certain  varieties  of  rales,  may 
thus  be  produced,  and  if  we  are  not  upon  our  guard,  may  lead  to 
errors  in  diagnosis.     Stethoscopes  which  have  no  hinges  and  which 
do  not  come  apart  are  far  less  likely  to  trouble  us  in  this  way. 

(5)  When  a  rubber  band  is  used  to  press  the  ear  pieces  more 
firmly  into  the  ears,  a  very  peculiar  sound  may  be  produced  by  the 
breathing  of  the  auscultator  as  it  strikes  upon  the  rubber  strap.     It 
is  a  loud  musical  note,  and  may  be  confused  with  coarse,  dry  rales. 

When  one  has  learned  to  recognize  and  to  disregard  the  noises 
produced  in  the  ways  above  indicated,  there  is  still  one  set  of 
sounds  which  are  very  frequently  heard,  yet  which  have  no  signifi- 
cance for  physical  diagnosis,  and  must  therefore  be  disregarded ;  I 
refer  to 

B.    Muscle  Sounds. 

Patients  who  hold  themselves  very  erect  while  being  exam- 
ined, or  who  for  any  reason  contract  the  muscles  of  that  portion  of 
the  chest  over  which  we  are  listening,  produce  in  these  muscles  a 
very  peculiar  and  characteristic  set  of  sounds.  The  contraction  of 
any  muscle  in  the  body  produces  sounds  similar  in  quality  to  those 
heard  over  the  chest,  but  of  less  intensity. 

Those  who  have  the  faculty  of  contracting  the  tensor  tyinpani 
muscle  at  will  can  at  any  time  listen  to  a  typical  muscle  sound. 
Or  close  both  ears  with  the  fingers  and  strongly  contract  the  mas- 
seter  muscle,  with  the  teeth  clenched.  A  high-pitched  muscle 
sound  will  be  heard. 

It  is  well  also  to  have  a  patient  contract  one  of  the  pectorals 
and  then  listen  to  the  sound  thus  produced.  In  some  cases  a  con- 
tinuous, low-pitched  roar  or  drumming  is  all  that  we  hear  ;  in  other 
cases  we  hear  nothing  but  the  breath  sounds  during  expiration, 
while  during  inspiration  the  breath  sound  is  obscured  by  a  series  of 


AUSCULTATION.  147 

short,  dull,  rumbling  sounds,  following  each  other  at  the  rate  of 
from  five  to  ten  in  a  second.  Occasionally  the  sound  is  like  the 
puffing  of  the  engine  attached  to  a  pile-driver,  or  like  a  stream  of 
water  falling  upon  a  sheet  of  metal  just  slowly  enough  to  be  sepa- 
rated into  drops  and  heard  at  a  considerable  distance.  As  already 
mentioned,  we  are  especially  apt  to  hear  these  muscle  sounds  dur- 
ing forced  inspiration,  owing  to  the  contraction  of  voluntary  mus- 
cles during  that  portion  of  the  respiratory  act.  They  are  most 
often  heard  over  the  upper  portion  of  the  chest  (over  the  pectorals 
in  front  and  over  the  trapezius  behind),  but  in  some  persons  no 
part  of  the  chest  is  free  from  them.  It  is  a  curious  fact  that  we 
are  not  always  able  to  detect  by  sight  or  touch  the  muscular  con- 
tractions which  give  rise  to  these  sounds,  and  the  patient  himself 
may  be  wholly  unaware  of  them.  Under  such  circumstances  they 
are  not  infrequently  mistaken  for  rales,  and  I  am  inclined  to  think 
that  many  of  the  sounds  recorded  as  "crumpling,"  "obscure," 
"muffled,"  "distant,"  or  "indeterminate"  rales  are  in  reality  due 
to  muscular  contractions.  The  adjectives  "muffled  "  and  "  distant " 
give  us  an  inkling  as  to  the  qualities  which  distinguish  muscular 
sounds  from  rales.  Kales  are  more  clean  cut,  have  a  more  distinct 
beginning  and  end,  seem  nearer  to  the  ear,  and  possess  more  of  a 
crackling  or  bubbling  quality  than  muscle  sounds. 

I  have  made  no  attempt  exhaustively  to  describe  all  the  sounds 
due  to  -muscular  contractions  and  conducted  to  the  ear  by  the  steth- 
oscope, but  have  intended  simply  to  call  attention  to  the  importance 
of  studying  them  carefully. 

C.    Other  Sources  of  Error. 

Another  source  of  confusion ,  which  for  beginners  is  very  trouble- 
some, especially  if  they  are  using  the  ordinary  form  of  stethoscope 
with  a  bell-shaped  chest  piece,  arises  in  case  the  chest  piece  is  not 
held  perfectly  in  apposition  with  the  skin.  If,  for  example,  the 
stethoscope  is  slightly  tilted  to  one  side  so  that  the  bell  is  lifted 
from  the  skin  at  some  point,  or  if  one  endeavors  to  listen  over  a 
very  uneven  part  of  the  chest  on  which  the  bell  of  the  stethoscope 
cannot  be  made  to  rest  closely,  a  roar  of  external  noises  reaches  the 


148 


PHYSICAL  DIAGNOSIS. 


ear  through  the  chink  left  between  the  chest  piece  and  the  chest 
After  a  little  practice  one  learns  instantly  to  detect  this  condition 
of  things  and  so  to  shift  the  position  of  the  chest  piece  that  exter- 
nal noises  are  totally  excluded  ;  but  by  the  beginner,  the  peculiar 
babel  of  external  noises  which  is  heard  whenever  the  stethoscope 
fails  to  fit  closely  against  the  chest  is  not  easily  recognized,  and 
hence  he  tends  to  attribute  some  of  these  external  sounds  to  diseased 
conditions  within  the  chest. 

Again,  it  is  not  until  we  have  had  considerable  practice  that 


FIG.  91.— Stethoscope  Held  Right  Side  Up.  FIG.  92.— Stethoscope  Held  Wrong  Side  Up. 

our  sense  of  hearing  comes  instantly  to  tell  us  when  something  is 
wrong  about  the  stethoscope  itself  ;  when,  for  example,  one  of  the 
tubes  is  blocked,  kinked,  or  disconnected,  or  when  we  are  hold- 
ing the  stethoscope  upside  down,  so  that  the  ear  pieces  point 
downward  instead  of  upward  (see  Figs.  91  and  92).  It  is  only 
when  we  have  learned  through  loug  practice  about  how  much  we 
ought  to  hear  at  a  given  point  in  the  normal  chest  that  we  recognize 
at  once  the  fact  that  we  are  not  hearing  as  much  as  we  should,  in 
case  some  one  of  the  above  accidents  has  happened.  Many  begin- 
ners do  not  listen  long  enough  in  any  one  place,  but  move  the  chest 
piece  of  the  stethoscope  about  rapidly  from  point  to  point,  as  they 
have  seen  experienced  auscultators  do  ;  but  it  is  remarkable  how 
much  more  one  can  hear  at  a  given  point  by  simply  persevering  and 


AUSCULTATION.  149 

listening  to  beat  after  beat,  or  breath  after  breath.  It  is  sometimes 
difficult  to  avoid  the  impression  that  the  sounds  themselves  have 
grown  louder  as  we  continue  to  listen,  especially  if  we  are  in  any 
doubt  as  to  what  we  hear.  Therefore,  if  we  hear  indistinctly,  it  is 
Important  to  keep  on  listening,  and  to  fix  the  attention  successively 
apon  each  of  the  different  elements  in  the  sounds  under  consideration. 
In  difficult  cases  we  should  use  every  possible  aid  toward  concen- 
tration of  the  attention,  and  where  it  is  possible,  all  sources  of  dis- 
traction should  be  eliminated.  Thus,  in  any  case  of  doubt,  I  think 
it  is  important  for  the  auscultator  to  get  himself  into  as  comfort- 
able a  position  as  he  can,  so  that  his  attention  is  not  distracted  by 
his  own  physical  discomforts.  Many  auscultators  shut  their  eyes 
when  listening  in  a  difficult  case  so  as  to  avoid  the  distraction  of 
impressions  coming  through  the  sense  of  sight.  It  goes  without 
saying  that  if  quiet  can  be  secured  in  the  room  where  we  are  work- 
ing, and  outside  it  as  well,  we  shall  be  enabled  to  listen  much  more 
profitably. 

AUSCULTATION  OF  THE  LUNGS. 

In  the  majority  of  cases  ordinary  quiet  breathing  is  not  forcible 
enough  to  bring  out  the  sounds  on  which  we  depend  for  the  diag- 
nosis of  the  condition  of  the  lungs.  Deep  or  forced  breathing  is 
what  we  need. 

As  a  rule,  the  patient  must  be  taught  how  to  breathe  deeply, 
which  is  best  accomplished  by  personally  demonstrating  the  act  of 
deep  breathing  and  then  asking  him  to  do  the  same.  Two  difficul- 
ties are  encountered: 

(a)  The  patient  may  blow  out  his  breath  forcibly  and  with  a 
noise,  since  that  is  what  he  is  used  to  doing  whenever  he  takes  a 
long  breath  under  ordinary  cr-cumstances;  or 

(b)  It  may  be  that  he  cannot  be  made  to  take  a  deep  breath  at 
all.     The  first  of  these  mistakes  alters  the  sounds  to  be  heard  with 
the  stethoscope  in  any  part  of  the  chest  by  disturbing  both  the 
rhythm  and  the  pitch  of  the  respiratory  sounds      In  this  way  the 
breathing  may  be  made  to  sound  tubular  or  asthmatic  throughout  a 
sound  chest.     This  difficulty  can  sometimes  be  overcome  by  demon- 
strating to  the  patient  that  what  you  desire  is  to  have  him  take  a 


150 


PHYSICAL  DIAGNOSIS. 


full  breath  and  then  simply  let  it  go,  but  not  blow  it  forcibly  out. 
In  some  cases  the  patient  cannot  be  taught  this,  and  we  have  to  get 
on  the  best  we  can  despite  his  mistakes.  When  he  cannot  be  made 
to  take  a  full  breath  at  all,  we  can  often  accomplish  the  desired  re- 
sult by  getting  him  to  cough.  The  breath  just  before  and  after  a 
cough  is  often  of  the  type  we  desire.  The  use  of  voluntary  cough 
in  order  to  bring  out  rales  will  be  discussed  later  on.  Another  use- 
ful manoeuvre  is  to  make  the  patient  count  aloud  as  long  as  he  can 
with  a  single  breath.  The  deep  inspiration  which  he  is  forced  to 
take  after  this  task  is  of  the  type  which  we  desire. 

I.  RESPIRATORY  TYPES. 

In  the  normal  chest  two  types  of  breathing  are  to  be  heard : 

(1)  Tracheal,  bronchial,  or  tubular  breathing. 

(2)  Vesicular  breathing. 

Tracheal,  bronchial,  or  tubular  breathing  is  to  be  heard  in  normal 
cases  if  the  stethoscope  is  pressed  against  the  trachea,  and  as  a  rule 


Fio.  93.— Situation  of  the  Trachea  and  Primary  Bronchi. 

it  can  also  be  heard  over  the  situation  of  the  primary  bronchi,  in 
front  or  behind  (see  Figs.  93  and  94). 

Vesicular  breathing  is  to  be  heard  over  the  remaining  portions  of 


AUSCULTATION.  151 

the  lung — that  is,  in  the  front  of  the  thorax  except  where  the  heart 
and  the  liver  come  against  the  chest  wall,  in  the  back  except  where 
the  presence  of  the  scapulae  obscures  it,  and  throughout  both  axillae. 

(1)  Characteristics  of  Vesicular  Breathing. 

Vesicular  breathing — that  heard  over  the  air  vesicles  or  paren- 
chyma of  the  lung — has  certain  characteristics  which  I  shall  try  to 
describe  in  terms  of  intensity,  duration,  and  pitch. 


FIG.  94.— Situation  of  the  Trachea  and  Primary  Bronchi. 

Of  the  quality  of  the  sounds  heard  over  this  portion  of  the  lung 
there  is  little  can  be  said ;  it  sounds  something  like  the  swish  of  the 
wind  in  a  grove  of  trees  some  distance  off,  and  hence  is  sometimes 
spoken  of  as  "breezy." 

The  intensity,  duration,  and  pitch  of  the  inspiration  as  compared 
with  that  of  the  expiration  may  be  represented  as  in  Fig.  95.  In 
this  figure,  as  in  all  those  to  be  used  in  description  of  respiratory 
sounds — 

(1)  I  represent  the  inspiration  by  an  up-stroke  and  the  expira- 
tion by  a  down-stroke  (see  the  direction  of  the  arrows  in  Fig    63). 

(2)  The  length  of  the  up-stroke  as  compared  with  that  of  the 
down-stroke  corresponds  to  the  length  of  inspiration  compared  with 
expiration. 


152 


PHYSICAL  DIAGNOSIS. 


(3)  The  thickness  of  the  up-stroke  as  compared  with  the  down- 
stroke  represents  the  intensity  of  the  inspiration  as  compared  with 
the  expiration. 

(4)  The  pitch  of  inspiration  as  compared  with  that  of  expi- 
ation is  represented  by  the  sharpness  of  the  angle  which  the  up- 


FIG.  95.— Vesicular  Breath- 
ing. 


FIG.  96.— Distant  Vesicular 
Breathing. 


FIG.   97.— Exaggerated  Ve- 
sicular Breathing. 


stroke  makes  with  the  perpendicular  as  compared  with  that  which 
the  down-stroke  makes  with  the  perpendicular.  The  pitch  of  a 
roof  may  be  thought  of  in  this  connection  to  remind  us  of  the  mean- 
ing of  these  symbols. 

If  now  we  look  again  at  Fig.  95  we  see  that  when  compared 
with  expiration  (the  down-stroke),  the  inspiration  is — 

(a)  More  intense. 

(#)  Longer. 

(c)  Higher  pitched. 

Our  comparison  is  invariably  made  between  inspiration  and  ex- 
piration, and  not  with  any  other  sound  as  a  standard. 

Now,  this  type  of  breathing  (which,  as  I  have  said,  is  to  be 
heard  over  every  portion  of  the  lung  except  those  portions  imme- 
diately adjacent  to  the  primary  bronchi),  is  not  heard  everywhere 
with  equal  intensity.  It  is  best  heard  below  the  clavicles  in  front, 
in  the  axillae,  and  below  the  scapulae  behind,  but  over  the  thin, 
lower  edges  of  the  lung,  whether  behind  or  at  the  sides,  it  is 
feebler,  though  still  retaining  its  characteristic  type  as  revealed  in 
the  inspiration  and  expiration  in  respect  to  intensity,  duration,  and 
pitch.  To  represent  distant  vesicular  breathing  graphically  we 
frave  only  to  draw  its  symbol  on  a  smaller  scale  (see  Fig.  96).  On 


AUSCULTATION. 


153 


the  other  hand,  when  one  listens  to  the  lungs  of  a  person  who  has 
been  exerting  himself  strongly,  one  hears  the  same  type  of  respira- 
tion, but  on  a  larger  scale,  which  may  then  be  represented  as  in 
Fig.  97.  This  last  symbol  may  also  be  used  to  represent  the  respi- 
ration which  we  hear  over  normal  but  thin-walled  chests ;  for  ex- 
ample, in  children  or  in  emaciated  persons.  It  is  sometimes  known 
as  "exaggerated"  or  "puerile"  respiration.  When  one  lung  is 
thrown  out  of  use  by  disease  so  that  increased  work  is  brought 
upon  the  other,  the  breath  sounds  heard  over  the  latter  are  increased 
and  seem  to  be  produced  on  a  larger  scale.  Such  breathing  is  some- 
times spoken  of  as  "  rough  "  breathing. 

It  is  very  important  to  distinguish  at  the  outset  between  the 
different  types  of  breathing,  one  of  which  I  have  just  described,  and 
the  different  degrees  of  loudness  with  which  any  one  type  of  breath- 
ing may  be  heard. 

(2)  Bronchial  or  Tracheal  Breathing  in  Health. 

Bronchial  breathing  may  be  symbolically  represented  as  in  Fig. 
98,  in  which  the  increased  length  of  the  down  stroke  corresponds 
to  the  increased  duration  of  expiration,  and  the  greater  thickness 


FIG.  98.— Bronchial  Breath- 
ing of  Moderate  Intensity. 


FIG.  99.— Distant  Bronchial 
Breathing. 


FIG.  100.— Very  Loud  Bron- 
chial Breathing. 


of  both  lines  corresponds  to  the  greater  intensity  of  both  sounds, 
expiratory  and  inspiratory,  while  the  sharp  pitch  of  the  "  gable  "  on 
both  sides  of  the  perpendicular  corresponds  to  the  high  pitch  of 
both  sounds.  Expiration,  it  will  be  noticed,  slightly  exceeds  inspi- 
ration both  in  intensity  and  pitch,  and  considerably  exceeds  it  in 
duration,  while  as  compared  with  vesicular  breathing  almost  all  the 


154  PHYSICAL  DIAGNOSIS. 

relations  are  reversed.  Bronchial  breathing  has  also  a  peculiar 
quality  which  can  be  better  appreciated  than  described. 

In  the  healthy  chest  this  type  of  breathing  is  to  be  heard  if  one 
listens  over  the  trachea  or  primary  bronchi  (see  above,  Fig.  91), 
but  practically  one  hardly  ever  listens  over  the  trachea  and  bronchi 
except  by  mistake,  and  the  importance  of  familiarizing  one's  self 
with  the  type  of  respiration  heard  over  these  portions  of  the  chest 
is  due  to  the  fact  that  in  certain  diseases,  especially  in  pneumonia 
and  phthisis,  we  may  hear  bronchial  breathing  over  the  parenchyma 
of  the  lung  where  normally  vesicular  breathing  should  be  heard. 

The  student  should  familiarize  himself  with  each  of  these  types 
of  breathing,  the  vesicular  and  the  bronchial,  concentrating  his  at- 
tention as  he  listens  first  upon  the  inspiration  and  then  upon  the 
expiration,  and  comparing  them  with  each  other,  first  in  duration, 
next  in  intensity,  and  lastly  in  pitch.  To  those  who  have  not  a 
musical  ear,  high-pitched  sounds  convey  the  general  impression  of 
being  shrill,  while  low-pitched  sounds  sound  hollow  and  empty,  but 
the  distinction  between  intensity  and  pitch  is  one  comparatively 
difficult  to  master.  Distant  bronchial  breathing  may  be  repre- 
sented in  Fig.  99,  and  is  to  be  heard  over  the  back  of  the  neck 
opposite  the  position  of  the  trachea  and  bronchi.  Fig.  100  repre- 
sents very  loud  bronchial  breathing  such  as  is  sometimes  heard  in 
pneumonia. 

(3)  Broncho-  Vesicular  Breathing  in  Health. 

As  indicated  by  its  name,  this  type  of  breathing  is  intermediate 
between  the  two  just  described,  hence  the  terms  "mixed  breath- 
ing," or  "atypical  breathing  "  ("unbestimmt ").  Its  characteristics 
may  be  symbolized  as  in  Fig.  101.  In  the  normal  chest  one  can  be- 
come familiar  with  broncho-vesicular  breathing,  by  examining  the 
apex  of  the  right  lung,  or  by  listening  over  the  trachea  or  one  of  the 
primary  bronchi,  and  then  moving  the  stethoscope  half  an  inch  at 
a  time  toward  one  of  the  nipples.  In  the  course  of  this  journey 
one  passes  over  points  at  which  the  breathing  has,  in  varying  de- 
grees, the  characteristics  intermediate  between  the  bronchial  type 
from  which  we  started  and  the  vesicular  type  toward  which  we  are 


AUSCULTATION. 


155 


moving.     Expiration  is  a  little  longer,  intenser,  or  higher  pitched 
than  in  vesicular  breathing,  and  inspiration  a  little  shorter,  feebler^, 


FIG.  101. — Two  Common  Types  of  Broncho- 
Vesicular  Breathing. 


A      f 


FIG.  102.—  Distant  Broncho-Vesicular  Breath- 
Ing. 


or  lower  pitched ;  but  since  these  characteristics  are  variously  com- 
bined, there  are  many  subvarieties  of  broncho-vesicular  breathing. 
Fig.  102  represents  two  types  of  distant  broncho-vesicular  breath- 
ing.1 

(4)      The  Breathing  in  Emphysema. 

A  glance  at  Fig.  103  will  call  up  the  most  important  features  of 
this  type  of  respiration.  The  inspiration  is  short  and  somewhat 
feeble,  but  not  otherwise  remarkable.  The  expiration  is  long, 
feeble,  and  low  pitched.  This  type  of  breathing  is  the  rule  in 
elderly  persons,  particularly  those  of  the  male  sex. 

(5)      The  Breathing  in  Asthma. 

Fig.  104  differs  from  emphysematous  only  in  the  greater  intensity 
of  the  inspiration.  In  this  type  of  breathing,  however,  both  sounds 


FIG.  103.— Emphysematous  Breathing. 


FIG.    104.— Asthmatic    Breathing.     «,  8,  & 
squeaking  (musical)  rales. 


are  usually  obscured  to  a  great  extent  by  the  presence  of  piping  and 
squeaking  rales  (see  below). 

.    l  The  right-haud  type  is  often  termed  "sharp  "  or  "rough." 


156 


PHYSICAL  DIAGNOSIS. 


(6)  Interrupted  or  "  Cogwheel  "  Breathing. 

As  a  rule,  only  the  inspiration  is  interrupted,  being  transformed 
into  a  series  of  short,  jerky  puffs  as  shown  in  Fig.  105.  Very  rarely 
the  expiration  is  also  divided  into  segments.  When  heard  over  the 
entire  chest,  cogwheel  breathing  is  usually  the  result  of  nervous- 
ness, fatigue,  or  chilliness  on  the  patient's  part.  With  the  removal 
of  these  causes  this  type  of  respiration  then  disappears.  If,  on  the 
other  hand,  cogwheel  respiration  is  confined  to  a  relatively  small 
portion  of  the  chest,  and  remains  present  despite  the  exclusion  of 


FIG.  105.— Cogwheel  Breathing. 


FIG.  106.— Metamorphosing  Breathing. 


fatigue,  nervousness,  or  cold,  it  points  to  a  local  catarrh  in  the  finei 
bronchi  such  as  to  render  difficult  the  entrance  of  air  into  the  alve- 
oli. As  such,  it  has  a  certain  significance  in  the  diagnosis  of  early 
phthisis,  a  significance  similar  to  that  of  rales  or  other  signs  of 
localized  bronchitis  (see  below) . 

(7)  Amphoric  or  Cavernous  Breathing  (see  below,  p.  161). 

(8)  Metamorphosing  Breathing. 

Occasionally,  while  we  are  listening  to  an  inspiration  of  normal 
pitch,  intensity,  and  quality,  a  sudden  metamorphosis  occurs  and  the 
type  of  breathing  changes  from  vesicular  to  bronchial  or  amphoric 
(see  Fig.  106),  or  the  intensity  of  the  breath  sounds  may  suddenly 
be  increased  without  other  change  These  metamorphoses  are  usu- 
ally owing  to  the  fact  that  a  plugged  bronchus  is  suddenly  opened 
by  the  force  of  the  inspired  air,  so  that  the  sounds  conducted 
through  it  become  audible. 


A  USC  ULTA  TION.  157 

II.  DIFFERENCES  BETWEEN  THE  Two  SIDES  OF  THE  CHEST. 

(a)  Over  the  apex  of  the  right  lung — that  is,  above  the  right 
clavicle  in  front,  and  above  the  spine  of  the  scapula  behind — one 
hears  in  the  great  majority  of  normal  chests  a  distinctly  broncho- 
vesicular  type  of  breathing.  In  a  smaller  number  of  cases  this 
same  type  of  breathing  may  be  heard  just  below  the  right  clavicle. 
These  facts  cannot  be  too  strongly  insisted  upon,  since  it  is  only 
by  bearing  them  in  mind  that  we  can  avoid  the  mistake  of  diagnos- 
ing a  beginning  consolidation  of  the  right  apex  where  none  exists. 
Breath  sounds  which  are  perfectly  normal  over  the  right  apex  would 
mean  serious  disease  if  heard  over  similar  portions  of  the  left  lung. 
It  will  be  remembered  that  the  apex  of  the  right  lung  is  also  duller 
on  percussion  than  the  corresponding  portion  of  the  left,  and  that 
the  voice  sounds  and  tactile  fremitus  are  normally  more  intense  on 
the  right  (see  Fig.  64) . 

(b~)  At  the  base  of  the .  left  lung  posteriorly  one  often  hears  a 
slightly  rougher  or  more  noisy  type  of  breathing  than  in  the  corre- 
sponding portion  of  the  right  lung.1 

III.  PATHOLOGICAL  MODIFICATIONS  OF  VESICULAR  BREATHING. 

Having  now  distinguished  the  different  types  of  breathing  and 
described  their  distribution  in  the  normal  chest,  we  must  return  to 
the  normal  or  vesicular  breathing  in  order  to  enumerate  certain  of 
its  modifications  which  are  important  in  diagnosis. 

(1)  Exaggerated  Vesicular  Breathing  ("  Compensatory  "  Breathing). 

(a)  It  has  already  been  mentioned  that  in  children  or  in  adults 
with  very  thin:  and  flexible  chests  the  normal  breath  sounds  are 
heard  with  relatively  great  distinctness ;  also  that  after  any  exer- 
tion which  leads  to  abnormally  deep  and  forcible  breathing  a  simi- 
lar increase  in  the  intensity  of  the  respiratory  sounds  naturally 
occurs. 

(b)  The  term  "compensatory  breathing,"  or  "vicarious"  breath- 
ing, refers  to  vesicular  breathing  of  an  exaggerated  type,  such  as  is 

1  If  the  patient  lies  on  the  side,  that  side  shows  a  slightly  more  tubular 
respiration  with  increased  voice,  whisper,  and  fremitus.  This  must  be  allowed 
for  in  all  comparisons  made  in  this  position. 

c.  -7 


158  PHYSICAL  DIAGNOSIS. 

heard,  for  example,  over  the  whole  of  one  lung  when  the  other  lung 
is  thrown  out  of  use  by  the  pressure  of  an  accumulation  of  air  01 
fluid  in  the  pleural  cavity.  A  similar  exaggeration  of  the  breathing 
upon  the  sound  side  takes  place  when  the  other  lung  is  solidified, 
as  by  tuberculosis,  pneumonia,  or  malignant  disease,  or  when  it  is 
compressed  by  the  adhesions  following  pleuritic  effusion,  or  by 
a  contraction  of  the  bones  of  that  side  of  the  chest  such  as  occurs 
in  spinal  curvature. 

(2)  Diminished  Vesicular  Breathing. 

The  causes  of  a  diminution  in  the  intensity  of  the  breath  sounds 
without  any  change  in  their  type  are  very  numerous.  I  shall  men- 
tion them  in  an  order  corresponding  as  nearly  as  possible  to  the 
relative  frequency  of  their  occurrence. 

(a)  Fluid,  Air,  or  Solid  in  the  Pleural  Cavity. — Probably  the 
commonest  cause  for  a  diminution  or  total  abolition  of  normal 
breath  sounds  is  an  accumulation  of  fluid  in  the  pleural  cavity  such 
as  occurs  in  inflammation  of  the  pleura  or  by  transudation  (hydro- 
thorax).  In  such  cases  the  layer  of  fluid  intervening  between  the 
lung  and  the  stethoscope  of  the  auscultator  causes  retraction  of  the 
lung  so  that  little  or  no  vesicular  murmur  is  produced  in  it,  and 
hence  none  is  transmitted  to  the  ear  of  the  auscultator.  An  ac- 
cumulation of  air  in  the  pleural  cavity  (pneumothorax)  may  dimin- 
ish or  abolish  the  breath  sounds  precisely  as  a  layer  of  fluid  does ; 
in  a  somewhat  different  way  a  thickening  of  the  costal  or  pulmo- 
nary pleura  or  a  malignant  growth  of  the  chest  wall  may  render 
the  breath  sounds  feeble  or  prevent  their  being  heard  because  the 
vibrations  of  the  thoracic  sounding-board  are  thus  deadened.  Which- 
ever of  these  causes,  fluid  or  air  or  solid,  intervenes  between  the  lung 
and  the  ear  of  the  auseultator,  the  breath  sounds  are  deadened  or 
diminished  without,  as  a  rule,  any  modification  of  their  type.  The 
amount  of  such  diminution  depends  roughly  on  the  thickness  of  the 
layer  of  extraneous  substance,  whether  fluid,  air,  or  solid. 

Total  absence  of  breath  sounds  may  therefore  be  due  to  any  one 
of  these  causes,  provided  the  layer  intervening  between  the  lung  and 
chest  wall  is  of  sufficient  thickness  to  produce  complete  atelectasis 
of  the  lung  or  to  deaden  the  vibrations  of  the  chest  wall. 


AUSCULTATION.  159 

(7»)  Emphysema  of  the  lung,  by  destroying  its  elasticity  and  re- 
ducing the  extent  of  its  movements,  makes  the  breath  sounds  rela- 
tively feeble,  but  seldom,  if- ever,  abolishes  them  altogether. 

(c)  In  bronchitis  the  breath  sounds  are  sometimes  considerably 
diminished  owing  to  the  filling  up  of  the  bronchi  with  secretion. 
This    diminution,  however,  usually  attracts   but  little  attention, 
owing  to  the  fact  that  the  bubbling  and  squeaking  sounds,  which 
result  from  the  passage  of  air  through  the  bronchial  secretions,  dis- 
tract our  notice  to  such  an  extent  that  we  find  it  difficult  to  con- 
centrate attention  upon  the  breath  sounds,  even  if  we  do  not  forget 
altogether  to  listen  to  them.     When,  however,  we  succeed  in  listen- 
ing through  the  rules  to  the  breath  sounds  themselves,  we  usually 
notice  that  they  are  very  feeble,  especially  over  the  lower  two- 
thirds  of  the  chest.      (Edema  of  the  lung  may  diminish  the  breath 
sounds  in  a  similar  way. 

(d)  Pain  in  the  thorax,  such  as  is  produced  by  dry  pleurisy  or 
intercostal  neuralgia,  diminishes  the  breath  sounds  because  it  leads 
the  patient  to  restrain,  so  far  as  possible,  the  movements  of  his 
chest,  and  so  of  his  lungs.     If,  for  any  other  reason,  the  full  ex- 
pansion of  the  lung  does  not  take  place,  whether  on  account  of  the 
feebleness  of  the  respiratory  movements  or  because  the  lung  is  me- 
chanically hindered  by  the  presence  of  pleuritic  adhesions,   the 
breath  sounds  are  proportionately  feeble. 

(e)  Occlusion  of  the  upper  air  passages,  as  by  spasm,  or  oedema 
of  the  glottis,  renders  the  breathing  very  feeble  on  both  sides  of 
the  chest.     If  one  of  the  primary  bronchi  is  occluded,  as  by  a  for- 
eign body  or  by  pressure  of  a  tumor  or  enlarged  gland  from  without, 
we  get  a  unilateral  enfeeblement  of  the  breathing  over  the  corre- 
sponding lung. 

(/)  Occasionally  a  paralysis  of  the  muscles  of  respiration  on  one 
or  both  sides  is  found  to  result  in  a  unilateral  or  bilateral  enfeeble- 
ment of  the  breathing. 

It  should  be  remembered,  when  estimating  the  intensity  of  the 
breathing,  that  the  sounds  heard  over  the  right  base  are,  as  a  rule, 
slightly  more  feeble  than  those  heard  over  the  left  base  in  the  nor- 
mal chest. 


160  PHYSICAL  DIAGNOSIS. 

IV.  BRONCHIAL  OB  TUBULAR  BREATHING  IN  DISEASE. 

(a)  I  have  already  described  the  occurrence  of  bronchial  breath- 
ing in  parts  of  the  normal  chest,  namely,  over  the  trachea  and  pri- 
mary bronchi.  In  disease,  bronchial  breathing  may  be  heard  else- 
where in  the  chest,  and  usually  points  to  solidification  of  that  portion 
of  lung  from  which  it  is  conducted.  It  is  heard  most  commonly  in 
phthisis  (see  below,  p.  304). 

(fy  Croupous  pneumonia  is  probably  the  next  most  frequent 
cause  of  bronchial  breathing,  although  by  no  means  every  case  of 
croupous  pneumonia  shows  this  sign.  For  a  more  detailed  account 
of  the  conditions  under  which  it  does  or  does  not  occur  in  croupous 
pneumonia,  see  below,  p.  296.  Lobular  pneumonia  is  rarely  mani- 
fested by  tubular  breathing. 

(c)  In  about  one-third  of  the  cases  of  pleuritic  effusion  distant 
bronchial  breathing  is  to  be  heard  over  the  fluid.     On  account  of 
the  feebleness  of  the  breath  sounds  in  such  cases  they  are  often 
put  down  as  absent,  as  we  are  so  accustomed  to  associate  intensity 
with  the  bronchial  type  of  breathing.     One  should  be  always  on 
the  watch  for  any  degree  of  intensity  of  bronchial  breathing  from 
the  feeblest  to  the  most  distinct. 

(d)  Rarer  causes  of  bronchial  breathing  are  hemorrhagic  infarc- 
tion of  the  lung,  syphilis,  or  malignant  disease,  any  one  of  which 
may  cause  a  solidification  of  a  portion  of  the  lung. 

V.  BRONCHO-VESICULAR  BREATHING  IN  DISEASE. 

Respiration  of  this  type  should  be  carefully  distinguished  from 
puerile  or  exaggerated  breathing,  in  which  we  hear  the  normal  vesic- 
ular respiration  upon  a  large  scale.  I  have  already  mentioned 
that  broncho-vesicular  breathing  is  normally  to  be  heard  over  the 
apex  of  the  right  lung.  In  disease,  broncho-vesicular  breathing  is 
heard  in  other  portions  of  the  lung,  and  usually  denotes  a  moderate 
degree  of  solidification  of  the  lung,  such  as  occurs  in  early  phthisis 
or  in  the  earliest  and  latest  stages  of  croupous  pneumonia.  In  cases 
of  pleuritic  effusion,  one  can  usually  hear  broncho-vesicular  breath- 


AUSCULTATION.  161 

ing  over  the  upper  portion  of  the  affected  side,  owing  to  the  retrac- 
tion of  the  lung  at  that  point. 

VI.  AMPHORIC  BREATHIXG  (Amphora  =  A  Jar). 

Respirations  having  a  hollow,  empty  sound  like  that  produced 
by  blowing  across  the  top  of  a  bottle,  are  occasionally  heard  in  dis- 
ease over  pulmonary  cavities  (e.g.,  in  phthisis)  or  in  pneumothorax, 
i.e.,  under  conditions  in  which  the  air  passes  in  and  out  of  a  large 
empty  cavity  within  the  chest.  Amphoric  breathing  never  occurs 
in  health.  The  pitch  of  both  sounds  is  low,  but  that  of  expiration 
lower  than  that  of  inspiration.  The  intensity  and  duration  of  the 
sounds  vary,  and  the  distinguishing  mark  is  their  quality  which 
resembles  that  of  a  whispered  "who." 

VII.  RALES. 

The  term  "rales  "  is  applied  to  sounds  produced  by  the  passage 
of  air  through  bronchi  which  contain  mucus  or  pus,  or  which  are 
narrowed  by  swelling  of  their  walls.1  Rales  are  best  classified  as 
follows : 

(1)  Bubbling  rales,   including  (a)   coarse,  (b)  medium,   and  (c) 
fine  rales. 

(2)  Crackling  rales  (large,  medium,  or  fine). 

The  smallest  varieties  of  this  type  are  known  as  "  crepitant "  or 
"subcrepitant"  rales. 

(3)  Musical  rales  (high  or  low  pitched). 

Each  of  these  varieties  will  now  be  described  more  in  detail. 

(T)  Bubbliny  Rales. 

The  nature  of  these  is  sufficiently  indicated  by  their  name. 
The  coarsest  or  largest  bubbles  are  those  produced  hi  the  trachea, 
and  ordinarily  known  as  the  "death  rattle."  Tracheal  rales  occur 

1  Kales  are  of  all  auscultatory  phenomena  the  easiest  to  appreciate,  pro- 
vided we  exclude  various  accidental  sounds  which  may  be  transmitted  to  the 
ear  as  a  result  of  friction  of  the  stethoscope  against  the  skin  or  against  the 
fingers  of  the  observer.     (See  above,  page  145.) 
11 


102  PHYSICAL  DIAGNOSIS. 

in  any  condition  involving  either  profound  unconsciousness  or  very 
great  weakness,  so  that  the  secretions  which  accumulate  in  the 
trachea  are  not  coughed  out.  Tracheal  rales  are  by  no  means  a 
sure  precursor  of  death,  although  they  are  very  common  in  the 
moribund  state.  They  can  usually  be  heard  at  some  distance  from 
the  patient  and  without  a  stethoscope.  In  catarrh  of  the  larger 
bronchi  large  bubbling  rales  are  occasionally  to  be 
heard.  In  phthisical  cavities  one  sometimes  hears 
coarse,  bubbling  rales  of  a  very  metallic  and  gurgling 
quality  (see  below,  p.  311).  The  finer  grades  of  rales 
correspond  to  the  finer  bronchi. 

In  the  majority  of  cases  these  rales  are  most  numer- 
IDT.  — EX-  ous  during  inspiration  and  especially  during  the  latter 
plosion  of  Fine  part  of  this  act.     Their  relation  to  respiration  may  be 
of  inspiration,  represented  graphically  as  in  Fig.  107,  using  large  dots 
for  coarse  rales  and  small  dots  for  fine  rales.     Musical 
rales  can  be  symbolized  by  the  letter  S  (squeaks). 

(2)  Crackling  Rales. 

These  differ  from  the  preceding  variety  merely  by  the  absence 
of  any  distinct  bubbling  quality.  They  are  usually  to  be  heard  in 
cases  of  bronchitis  in  which  the  secretions  are  unusually  tenacious 
and  viscid.  They  are  especially  apt  to  come  at  the  end  of  inspira- 
tion, a  large  number  being  evolved  in  a  very  short  space  of  time,  so 
that  one  often  speaks  of  an  "explosion  of  fine  crackling  rales"  at 
the  end  of  inspiration.  Crackling  rales  are  to  be  heard  in  any  one 
of  the  conditions  in  which  bubbling  rales  occur,  but  are  more  fre- 
quent in  tuberculosis  than  in  simple  bronchitis. 

Crepitant  rales,  which  represent  the  finest  sounds  of  this  type, 
are  very  much  like  the  noise  which  is  heard  when  one  takes  a  lock 
of  hair  between  the  thumb  and  first  finger  and  rubs  the  hairs  upon 
each  other  while  holding  them  close  to  the  ear.  A  very  large  num- 
ber of  minute  crackling  sounds  is  heard  following  each  other  in 
rapid  succession.  To  the  inexperienced  ear  they  may  seem  to  blend 
into  a  continuous  sound,  but  with  practice  the  component  parts  may 


A  USCULTA  TION.  163 

be  distinguished.  This  type  of  rales  is  especially  apt  to  occur  dur- 
ing inspiration  alone,  but  not  very  infrequently"  they  are  heard 
during  expiration  as  well.  From  subcrepitant  rales  they  are  dis- 
tinguished merely  by  their  being  still  finer  than  the  latter. '  Sub- 
crepitant rales  are  often  mixed  with  sounds  of  a  somewhat  coarser 
type,  while  crepitant  rales  are  usually  all  of  a  size.  If  the 
chest  is  covered  with  hair,  sounds  precisely  like  these  two  varieties 
of  rales  may  be  heard  when  the  stethoscope  is  placed  upon  the  hairy 
portions.  To  avoid  mistaking  these  sounds  for  rales  one  must 
thoroughly  wet  or  grease  the  hair. 

Crepitant  Rales  in  Atelectasis. 

Crepitant  and  subcrepitant  rales  are  very  often  to  be  heard  along 
the  thin  margins  of  the  lungs  at  the  base  of  the  axillae  and  in  the 
back,  especially  when  a  patient  who  is  breathing  superficially  first 
begins  to  take  deep  breaths.  In  such  cases,  they  usually  disappear 
after  the  few  first  respirations,  and  are  then  to  be  explained  by  the 
tearing  apart  of  the  slightly  agglutinated  surfaces  of  the  finer  bron- 
chioles. 

It  is  by  no  means  invariably  the  case,  however,  that  such  sub- 
crepitant rales  are  merely  transitory  in  their  occurrence.  In  a  large 
number  of  cases  they  persist  despite  deep  breathing.  The  fre- 
quency of  subcrepitant  rales,  persistent  or  transitory,  heard  over 
the  inferior  margin  of  the  normal  lung  at  the  bottom  of  the  axilla, 
is  shown  by  the  following  figures :  Out  of  356  normal  chests  to 
which  I  have  listened  especially  for  these  rales,  I  found  228,  or  61 
per  cent,  which  showed  them  on  one  or  both  sides.  They  are  very 
rarely  to  be  heard  in  persons  under  twenty  years  o*  age.  After 
forty-five,  on  the  other  hand,  it  is  unusual  not  to  find  them. 
In  my  experience  they  are  considerably  more  frequent  in  the  situa- 
tion shown  in  Fig.  158  than  in  any  other  part  of  the  lung,  but  they 
may  be  occasionally  heard  in  the  back  or  elsewhere.  In  view  of 

'A  distinction  was  formerly  drawn  between  crepitant  and  subcrepitant 
rales,  on  the  ground  that  the  latter  were  heard  during  both  respiratory  sounds, 
and  the  former  only  during  inspiration,  but  this  distinction  cannot  be  main- 
lined and  is  gradually  being  given  up. 


164  PHYSICAL  DIAGNOSIS. 

these  facts,  it  seems  to  me  that  we  must  recognize  that  it  is  almost 
if  not  quite  physiological  to  find  the  finer  varieties  of  crackling 
rales  at  the  base  of  the  axillae  in  persons  over  forty  years  old.  I 
have  supposed  these  rales  to  be  due  to  a  partial  atelectasis  result- 
ing from  disuse  of  the  thin  lower  margin  of  the  lungs.  Such  por- 
tions of  the  lung  are  ordinarily  not  expanded  unless  the  respirations 
are  forced  and  deep.1  This  explanation  Avould  agree  with  the  obser- 
vations of  Abrauis,  to  which  I  shall  refer  later  (see  below,  p.  361). 

(b)  Crepitant  or  subcrepioant  rales  are  also  to  be  heard  in  a 
certain  portion  of  cases  of  pneumonia,  in  the  very  earliest  stages 
and  when  resolution  is  taking  place  ("crepitans  redux").  More 
rarely  this  type  of  rale  may  be  heard  in  connection  with  tubercu- 
losis, infarction,  or  oedema  of  the  lung. 

In  certain  cases  of  dry  pleurisy  there  occur  fine  crackling 
sounds  which  can  scarcely  be  differentiated  from  subcrepitant  rales. 
I  shall  return  to  the  description  of  them  in  speaking  of  pleura1, 
friction  (see  below,  p.  336)- 

(3)  Musical  Rales. 

The  passage  of  air  through  bronchial  tubes  narrowed  by  inflam- 
matory swelling  of  their  lining  membrane  (bronchitis),  or  by  spas- 
modic contraction  (asthma),  gives  rise  not  infrequently  to  a  mul- 
titude of  musical  sounds.  Such  a  stenosis  occurring  in  relatively 
large  bronchial  tubes  produces  a  deep-toned  groaning  sound,  while 
narrowing  of  the  finer  tubes  results  in  piping,  squeaking,  whistling 
noises  of  various  qualities.  Such  sounds  are  often  known  as  "  dry 
rules"  in  contradistinction  to  the  "bubbling  rales"  above  described, 
but  as  many  non-musical  crackling  rales  have  also  a  very  dry  sound, 
it  seems  to  me  best  to  apply  the  more  distinctive  term  "  musical 
rales"  to  all  adventitious  sounds  of  distinctly  musical  quality,  giv- 
ing up  the  term  "  dry  "  altogether.  Musical  rales  are  of  all  adven- 
titious sounds  the  easiest  to  recognize  but  also  the  mos^t  fugitive 
and  changeable.  They  appear  now  here,  now  there,  shifting  from 
minute  to  minute,  and  may  totally  disappear  from  the  chest  and 
reappear  again  within  a  very  short  time.  This  is  to  some  extent 

1  So  as  to  expand  the  lung  and  produce  the  "  entfaltungsgerausch  "  of  th» 
Germans. 


AUSCULTATION.  165 

true  of  all  varieties  of  r&les,  but  especially  of  the  squeaking  and 
groaning  varieties. 

Musical  rales  are  heard,  as  a  rule,  more  distinctly  during  expira- 
tion, especially  when  they  occur  in  connection  with  asthma  or  em- 
physema. In  these  diseases  one  may  hear  quite  complicated  chords 
from  the  combinations  of  rales  which  vary  in  pitch. 

VII.     THE  EFFECTS  OF  COUGH. 

The  influence  of  coughing  upon  rales  may  be  either  to  intensify 
them  and  bring  them  out  where  they  have  not  previously  been 
heard,  or  to  clear  them  away  altogether.  Lateral  decubitus  multi- 
plies and  intensifies  rales  on  the  lower  side.  Other  effects  of 
coughing  upon  physical  signs  will  be  mentioned  later  (pp.  297, 
306). 

VIII.     PLEURAL  FRICTION. 

The  surfaces  of  the  healthy  pleural  cavity  are  lubricated  with 
sufficient  sen-m  to  make  them  pass  noiselessly  over  each  other  dur- 
ing the  -Bents  of  respiration.  But  when  the  tissues  become 
abnormally  dry,  as  in  Asiatic  cholera,  or  when  the  serous  surfaces 
are  roughened  by  the  presence  of  a  fibrinous  exudation,  as  in  ordi- 
nary pleurisy,  the  rubbing  of  the  two  pleural  surfaces  against  one 
another  produces  peculiar  and  very  characteristic  sounds  known  as 
"pleural  friction  sounds."  The  favorite  seat  of  pleural  friction 
sounds  is  at  the  bottom  of  the  axilla,  i.e.,  where  the  lung  makes 
the  widest  excursion  and  where  the  costal  and  diaphragmatic  pleura 
are  in  close  apposition  (see  Fig.  65).  In  some  cases  pleural  fric- 
tion sounds  are  to  be  heard  altogether  below  the  level  of  the  lung. 
In  others  they  may  extend  ur>  several  inches  above  its  lower  mar- 
gin, and  occasionally  it  happens  that  friction  may  be  appreciated 
over  the  whole  lung  from  the  top  to  the  bottom.  Very  rarely 
friction  sounds  are  heard  only  at  the  apex  of  the  lung  in  early 
tuberculosis. 

The  sound  of  pleural  friction  may  be  closely  imitated  by  hold- 
ing the  thumb  and  forefinger  close  to  the  ear,  arid  rubbing  them 
past  each  other  with  strong  pressure,  or  by  pressing  the  palm  of 
one  hand  over  the  ear  and  rubbing  upon  the  back  of  this  hand  with 


166  PHYSICAL  DIAGNOSIS. 

the  fingers  of  the  other.  Pleural  friction  is  usually  a  catch 
jerky,  interrupted,  irregular  sound,  and  is  apt  to  occur  during  in- 
spiration only,  and  particularly  at  the  end  of  this  act.  It  may, 
however,  be  heard  with  both  respiratory  acts,  but  rarely  if  ever 
occurs  during  expiration  alone.  The  intensity  and  quality  of  the 
sounds  vary  a  great  deal,  so  that  they  may  be  compared  to  grazing, 
rubbing,  rasping,  and  creaking  sounds.  They  are  sometimes  spoken 
of  as  "  leathery."  As  a  rule,  they  seem  very  near  to  the  ear,  and  are 
sometimes  startlingly  loud.  In  many  cases  they  cannot  be  heard 
after  the  patient  has  taken  a  few  full  breaths,  probably  because  the 
rough  pleural  surfaces  are  smoothed  down  temporarily  by  the  fric- 
tion which  deep  breathing  produces.  After  a  short  rest,  however, 
and  a  period  of  superficial  breathing,  pleural  friction  sounds  often 
return  and  can  be  heard  for  a  short  time  with  all  their  former  in- 
tensity. They  are  increased  by  pressure  exerted  upon  the  outside 
of  the  chest  wall.  Such  pressure  had  best  be  made  with  the  hand 
or  with  the  Bowles  stethoscope,  since  the  sharp  edges  of  the  chest- 
piece  of  the  ordinary  stethoscope  may  give  rise  to  considerable 
pain;  but  if  such  pressure  is  made  with  the  hand,  one  must  be 
careful  not  to  let  the  hand  shift  its  position  upon  the  skin,  else 
rubbing  sounds  may  thus  be  produced  which  perfectly  simulate 
pleural  friction.  In  well-marked  cases  pleuritic  friction  can  be 
felt  if  the  palm  of  the  hand  is  laid  over  the  suspected  area ;  occa- 
sionally the  sound  is  so  loud  that  it  can  be  heard  by  the  patient 
himself  or  by  those  around  him. 

In  doubtful  cases,  or  when  a  friction  sound  appears  to  have 
disappeared,  and  when  one  wishes  to  bring  it  out  again,  there  are 
several  manoeuvres  suggested  by  Abrams  for  obtaining  this  enr" 

(a)  The  Arm  Manoeuvre. 

The  patient  suspends  respiration  altogether,  and  the  arm  iipon 
the  affected  side  is  raised  over  the  head  by  the  patient  himself  or 
by  the  physician,  as  in  performing  Sylvester's  method  of  artificial 
respiration.  During  this  movement  we  listen  over  the  suspected  area. 
"  By  this  manoeuvre  the  movement  of  the  parietal  against  the  vis- 
ceral pleura  is  opposite  in  direction  to  that  occurring  during  the 


AUSCULTATION.  167 

respiratory  act,  and  for  this  reason  the  pleuritic  sound  may  often 
be  elicited  after  it  has  been  exhausted  in  the  ordinary  act  of  breath- 


ing." 


The  Decubital  Manoeuvre. 


"Let  the  patient  lie  upon  the  affected  side  for  a  minute  or  two, 
then  let  him  rise  quickly  and  suspend  respiration.  Now  listen  over 
the  affected  area,  at  the  same  time  directing  the  patient  to  take  a 
deep  breath. " 

Pleuritic  friction  sounds  are  distinguished  from  rales  by  their 
greater  superficiality,  by  their  jerky,  interrupted  character,  by  the 
fact  that  they  are  but  little  influenced  by  cough,  and  that  they  are 
increased  by  pressure.  It  has  already  been  mentioned,  however, 
that  there  is  one  variety  of  sounds  which  we  have  every  reason  to 
think  originate  in  the  pleura,  which  cannot  be  distinguished  from 
certain  varieties  of  crackling  bronchial  rales.  Such  sounds  occur 
chiefly  in  connection  with  phthisical  processes,  in  which  both  pleu- 
risy and  bronchitis  are  almost  invariably  present,  and  it  is  seldom 
of  importance  to  distinguish  the  two. 

IX.  AUSCULTATION  OF  THE  SPOKEN  OB  WHISPERED  VOICE  SOUNDS. 
The  more  important  of  these  is : 

(a)  The  Whispered  Voice. 

The  patient  is  directed  to  whisper  "one,  two,  three,"  or 
"ninety -nine,"  while  the  auscultator  listens  over  different  portions 
of  the  chest  to  see  to  what  degree  the  whispered  syllables  are  trans- 
mitted. In  the  great  majority  of  normal  chests  the  whispered 
voice  is  to  be  heard  only  over  the  trachea  and  primary  bronchi  in 
front  and  behind,  while  over  the  remaining  portions  of  the  lung 
little  or  no  sound  is  to  be  heard.  When,  on  the  other  hand,  solidi- 
fication of  the  lung  is  present,  the  whispered  voice  may  be  dis- 
tinctly heard  over  portions  of  the  lung  relatively  distant  from  the 
trachea  and  bronchi;  for  example,  over  the  lower  lobes  of  the  lung 
behind.  The  usefulness  of  the  whispered  voice  in  the  search  for 
small  areas  of  solidification  or  for  the  exact  boundaries  of  a  solidi- 


168  PHYSICAL  DIAGNOSIS. 

fied  area  is  very  great,  especially  when  we  desire  to  save  the  patient 
the  pain  and  fatigue  of  taking  deep  breaths.  Whispered  voice 
sounds  are  practically  equivalent  to  a  forced  expiration  and  can  be 
obtained  with  very  little  exertion  on  the  patient's  part.  The  in- 
creased transmission  of  the  whispered  voice  is,  in  my  opinion,  a 
more  delicate  test  for  solidification  than  tubular  breathing.  The 
latter  sign  is  present  only  when  a  considerable  area  of  lung  tissue 
is  solidified,  while  the  increase  of  the  whispered  voice  may  be  ob- 
tained over  much  smaller  areas.  Retraction  of  the  lung  above  the 
level  of  a  pleural  effusion  causes  a  moderate  increase  in  the  trans- 
mission of  the  whispered  voice,  and  at  times  this  increased  or  bron- 
chial whisper  is  to  be  heard  over  the  fluid  itself,  probably  by  trans- 
mission from  the  compressed  lung  above. 

Where  the  lung  is  completely  solidified  the  whispered  words 
may  be  clearly  distinguished  over  the  affected  area.  In  lesser  de- 
grees of  solidification  the  syllables  are  more  or  less  blurred. 

(b)  The  Spoken  Voice. 

The  evidence  given  us  by  listening  for  the  spoken  voice  in  vari- 
ous parts  of  the  chest  is  considerably  less  in  value  than  that  obtained 
through  the  whispered  voice.  As  a  rule,  it  corresponds  with  the 
tactile  fremitus,  being  increased  in  intensity  by  the  same  causes 
which  increase  tactile  fremitus,  viz.,  solidification  or  condensation 
of  the  lung,  and  decreased  by  the  same  causes  which  decrease  tac- 
tile fremitus — namely,  by  the  presence  of  air  or  water  in  the  pleu- 
ral cavity,  by  the  thickening  of  the  pleura  itself,  or  by  an  ob- 
struction of  the  bronchus  leading  to  the  part  over  which  we  are 
listening.  In  some  cases  the  presence  of  solidification  of  the  lung 
gives  rise  not  merely  to  an  increase  in  transmission  of  the  spoken 
voice,  but  to  a  change  in  its  quality,  so  that  it  sounds  abnormally 
concentrated,  nasal,  and  near  to  the  listener's  ear.  The  latter 
change  may  be  heard  over  areas  where  tactile  fremitus  is  not  in- 
creased, and  even  where  it  is  diminished.  Where  this  change  in 
the  quality  of  the  voice  occurs,  the  actual  words  spoken  can  often 
be  distinguished  in  a  way  not  usually  possible  over  either  normal 
or  solidified  lung.  "Bronchophony,"  or  the  distinct  transmission 


AUSCULTATION.  169 

of  audible  words,  and  not  merely  of  diffuse,  unrecognizable  voice 
sounds,  is  considerably  commoner  in  the  solidifications  due  to  pneu- 
monia than  in  those  due  to  phthisis;  it  occurs  in  some  cases  of 
pneumothorax  and  pulmonary  cavity. 

(c)  Egophony. 

Among  the  least  important  of  the  classical  physical  sign?  is  a 
nasal  or  squeaky  quality  of  the  sounds  which  reach  the  observer's 
ear  when  the  patient  speaks  in  a  natural  voice.  To  this  peculiar 
quality  of  voice  the  name  of  "egophony"  has  been  given.  It  is 
most  frequently  heard  in  cases  of  moderate-sized  pleuritic  effusion 
just  about  the  level  of  the  lower  angle  of  the  scapula  and  in  the 
vicinity  of  that  point.  Less  often  it  is  heard  at  the  same  level  in 
front.  It  is  very  rarely  heard  in  the  upper  portion  of  the  chest 
and  is  by  no  means  constant  either  in  pleuritic  effusion  or  in  any 
other  condition.  A  point  at  which  it  is  heard  corresponds  not,  as 
a  rule,  with  the  upper  level  of  the  accumulated  fluid,  as  has  been 
frequently  supposed,  but  often  with  a  point  about  an  inch  farther 
down.  The  presence  of  egophony  is  in  no  way  distinctive  of  pleu- 
ritic effusions  and  may  be  heard  occasionally  over  solidified  lung. 

X.  PHENOMENA  PECULIAR  TO  PNEUMOHYDROTHORAX  AND  PNETJ- 

MOPYOTHORAX. 

(1)   Succussion  Sounds. 

Now  and  then  a  patient  consults  a  physician,  complaining  that 
he  hears  noises  inside  him  as  if  water  were  being  shaken  about. 
One  such  patient  expressed  himself  to  me  to  the  effect  that  he  felt 
"  like  a  half-empty  bottle."  In  the  chest  of  such  a  patient,  if  one 
presses  the  ear  against  any  portion  of  the  thorax  and  then  shakes 
the  whole  patient  strongly  (succussion),  one  may  hear  loud  splash- 
ing sounds  due  to  air  and  fluid  within.  The  sound  itself  is  often 
miscalled  "succussion."  Such  sounds  are  absolutely  diagnostic  of 
the  presence  of  both  air  and  fluid.  Very  frequently  they  may  be 
detected  by  the  physician  when  the  patient  is  not  aware  of  their 


170  PHYSICAL  DIAGNOSIS. 

presence.  Occasionally  the  splashing  of  the  fluid  within  may  be 
felt  as  well  as  heard.  It  is  essential,  of  course,  to  distinguish 
splashing  due  to  the  presence  of  air  and  fluid  in  the  pleural 
cavity  from  similar  sounds  produced  in  the  stomach,  but  this  is  not 
at  all  difficult  in  the  majority  of  cases.  It  is  a  bare  possibility  that 
succussion  sounds  may  be  due  to  the  presence  of  air  and  fluid  in  the 
pericardial  cavity. 

It  is  important  to  remember  that  splashing  is  never  to  be  heard 
in  simple  pleuritic  effusion  or  hydrothorax.  The  presence  of  air,  as 
well  as  liquid,  in  the  pleural  cavity  is  absolutely  essential  to  the 
production  of  succussion  sounds.1 

(2)  Metallic  Tinkle  or  Falling-Drop  Sound. 

When  listening  over  a  pleural  cavity  which  contains  both  air 
and  fluid,  one  occasionally  hears  a  liquid,  tinkling  sound,  due  pos- 
sibly to  the  impact  of  a  drop  of  liquid  falling  from  the  relaxed  lung 
above  into  the  accumulated  fluid  at  the  bottom  of  the  pleural  cavity, 
but  probably  to  rales  produced  in  the  tissues  around  the  cavity.  It 
is  stated  that  this  physical  sign  may  in  rare  cases  be  observed  in 
large-sized  phthisical  cavities  as  well  as  in  pneumohydrothorax  and 
pneumopyothorax. 

(3)  The  Lung-Fistula  Sound. 

When  a  perforation  of  the  lung  occurs  below  the  level  of  the 
fluid  accumulated  in  the  pleural  cavity,  bubbles  of  air  may  be  forced 
out  from  the  lung  and  up  through  the  fluid  with  a  sound  reminding 
one  of  that  made  by  children  when  blowing  soap-bubbles. 

1  It  is  well  for  the  student  to  try  for  himself  the  following  experiment, 
which  I  have  found  useful  in  impressing  these  facts  upon  the  attention  of 
classes  in  physical  diagnosis:  Fill  an  ordinary  rubber  hot-water  bag  to  the 
brim  with  water.  Invert  it  and  squeeze  out  forcibly  a  certain  amount  (per- 
haps half)  of  the  contents,  by  grasping  the  upper  end  of  the  bag  and  compress- 
ing it.  While  the  water  is  thus  being  forced  out,  screw  in  the  nozzle  of  the 
bag.  Now  shake  the  whole  bag,  and  it  will  be  found  impossible  to  produce 
any  splashing  sounds  owing  to  the  fact  that  there  is  no  air  in  the  bag.  Un- 
screw the  nozzle,  admit  air,  and  then  screw  it  in  again.  Now  shake  the  bag 
again  and  loud  splashing  will  be  easily  heard. 


CHAPTER  VIII. 

AUSCULTATION  OF  THE  HEAKT. 

I.   "VALVE  AREAS." 

IN  the  routine  examination  of  the  heart,  most  observers  listen 
in  four  places : 

(1)  At  the  apex  of  the  heart  in  the  fifth  intercostal  space  neai 
the  nipple,  the  "mitral  area." 


Aortic  area.  r  - 


Tricuspid  area. 


_i —    Pulmonic  area. 


-77-7 '  Mitral  area. 


FIG.  108.— The  Valve  Areas. 


(2)  In  the  second  left  intercostal  space  near  the  sternum,  the 
'''pulmonic  area." 

(3)  In  the  second  right  intercostal  space  near  the  sternum,  the 
''l  aortic  area." 

(4)  At  the  bottom  of  the  sternum  near  the  ensiform  cartilage, 
the  "  tricuspid  area." 

These   points   are   represented  in  Fig.  108  and  are  known  as 


172  PHYSICAL  DIAGNOSIS. 

"valve  areas."  They  do  not  correspond  to  the  anatomical  position 
of  any  one  of  the  four  valves,  but  experience  has  shown  that  sounds 
heard  best  at  the  apex  can  be  proved  (by  post-mortem  examination 
or  otherwise)  to  be  produced  at  the  mitral  orifice.  Similarly  sounds 
heard  best  in  the  second  left  intercostal  space  are  proved  to  be 
produced  at  the  pulmonary  orifice ;  those  which  are  loudest  at  the 
second  right  intercostal  space  to  be  produced  at  the  aortic  orifice ; ' 
while  those  which  are  most  distinct  near  the  origin  of  the  ensiform 
cartilage  are  produced  at  the  tricuspid  orifice. 

II.  THE  NORMAL  HEART  SOUNDS. 

A  glance  at  Fig.  109,  which  represents  the  anatomical  positions 
of  the  four  valves  above  referred  to,  illustrates  what  I  said  above ; 
namely,  that  the  traditional  valve  areas  do  not  correspond  at  all 
with  the  anatomical  position  of  the  valves.  If  now  we  listen  in 
the  "mitral  area,"  that  is,  in  the  region  of  the  apex  impulse  of  the 
heart,  keeping  at  the  same  time  one  finger  on  some  point  at  which 
the  cardiac  impulse  is  palpable,  one  hears  with  each  outward  thrust 
of  the  heart  a  low,  dull  sound,  and  in  the  period  between  the  heart 
beats  a  second  sound,  shorter  and  sharper  in  quality.2 

That  which  occurs  with  the  cardiac  impulse  is  known  as  the 
first  sound  ;  that  which  occurs  between  each  two  beats  of  the  heart 
is  known  as  the  second  sound.  The  second  sound  is  genei  illy  ad- 
mitted to  be  due  to  the  closure  of  the  semilunar  valves  The  cause 
of  the  first  sound  has  been  a  most  fruitful  source  of  discussion,  and 
no  one  explanation  of  it  can  be  said  to  be  generally  received.  Per- 
haps the  most  commonly  accepted  view  attributes  the  first  or 
systolic  sound  of  the  heart  to  a  combination  of  two  elements — 

(a)  The  contraction  of  the  heart  muscle  itself. 

(b)  The  sudden  tautening  of  the  mitral  curtains. 

Following  the  second  sound  there  is  a  pause  corresponding  to 

1  For  exceptions  to  this  rule,  see  below,  page  235. 

*  The  first  sound  of  the  heart,  as  heard  at  the  apex,  may  be  imitated  by 
holding  a  linen  handkerchief  by  the  corners  and  suddenly  tautening  one  of  the 
borders.  To  imitate  the  second  sound,  use  one-half  the  length  of  the  border 
instead  of  the  whole. 


AUSCULTATION  OF  THE  HEART. 


173 


the  diastole  of  the  heart.  Normally  this  pause  occupies  a  little 
more  time  than  the  first  and  second  sounds  of  the  heart  taken  to- 
gether. In  disease  it  may  be. much  shortened. 

The  first  sound  of  the  heart  is  not  only  longer  and  duller  than 
the  second  (it  is  often  spoken  of  as  "  booming  "  in  contrast  with  the 
"  snapping  "  quality  of  the  second  sound)  but  is  also  considerably 
more  intense,  so  that  it  gives  us  the  impression  of  being  accented 
like  the  first  syllable  of  a  trochaic  rhythm.  After  a  little  practice 
one  grows  so  accustomed  to  this  rhythm  that  one  is  apt  to  rely  upon 


Tricuspid  valve.  --  — 


„—  Pulmonic  valve. 

Aortic  valve. 

Mitral  valve. 


FIG.  109. -Anatomical  Position  of  the  Cardiac  Valves. 

his  appreciation  of  the  rhythm  alone  for  the  identification  of  the 
systolic  sound.  This  is,  however,  an  unsafe  practice  and  leads  to 
many  errors.  Our  impression  as  to  which  of  the  two  sounds  of  each 
cardiac  cycle  corresponds  to  systole  should  always  be  verified  either 
by  sight  or  touch.  We  must  either  see  or  feel  the  cardiac  impulse 
and  assure  ourselves  that  it  is  synchronous  with  the  heart  sound 
which  we  take  to  be  systolic.1  This  point  is  of  especial  importance 
in  the  recognition  and  identification  of  cardiac  murmurs,  as  will  be 
seen  presently. 

1  When  the  cardiac  impulse  can  be  neither  seen  nor  felt,  the  pulsation  of 
the  carotid  will  generally  guide  us.     The  radial  pulse  is  not  a  safe  guide. 


174  PHYSICAL  DIAGNOSIS. 

So  far,  I  have  been  describing  the  normal  heart  sounds  heard 
in  the  "mitral  area,"  that  is,  at  the  apex  of  the  heart.  If  now  we 
listen  over  the  pulmonary  area  (in  the  second  left  intercostal 
space),  we  find  that  the  rhythm  of  the  heart  sounds  has  changed 
and  that  here  the  stress  seems  to  fall  upon  the  "second  sound," 
i.e.,  that  corresponding  to  the  beginning  of  diastole;  in  other 
words,  the  first  sound  of  the  heart  is  here  heard  more  feebly  and 
the  second  sound  more  distinctly.  The  sharp,  snapping  quality  of 
the  latter  is  here  even  more  marked  than  at  the  apex,  and  despite 
the  feebleness  of  the  first  sound  in  this  area  we'  can  usually  recog- 
nize its  relatively  dull  and  prolonged  quality. 

Over  the  aortic  area  (i.e.,  in  the  second  right  interspace)  the 
rhythm  is  the  same  as  in  the  pulmonary  area,  although  the  second 
sound  may  be  either  stronger  or  weaker  than  the  corresponding 
sound  on  the  other  side  of  the  sternum  (see  below,  p.  176). 

Over  the  tricuspid  area  one  hears  sounds  practically  indistin- 
guishable in  quality  and  in  rhythm  from  those  heard  at  the  apex. 

When  the  chest  walls  are  thick  and  the  cardiac  sounds  feeble, 
it  may  be  difficult  to  hear  them  at  all.  In  such  cases  the  heart 
sounds  may  be  heard  much  more  distinctly  if  the  patient  leans  for- 
ward and  toward  his  own  left.  Such  a  position  of  the  body  also  ren- 
ders it  easier  to  map  out  the  outlines  of  the  cardiac  dulness  by  per- 
cussion if  we  allow  for  the  swing  of  the  heart  to  the  left. 

In  cardiac  neuroses  and  during  conditions  of  excitement  or  emo- 
tional strain,  the  first  sound  at  the  apex  is  not  only  very  loud  but 
has  often  a  curious  metallic  reverberation  ("  cliquetis  metallique") 
corresponding  to  the  trembling,  jarring  cardiac  impulse  (often  mis- 
taken for  a  thrill)  which  palpation  reveals. 

III.   MODIFICATIONS  IN  THE  INTENSITY  OF  THE  HEART   SOUNDS. 

It  has  already  been  mentioned  that  in  young  persons  with  thin, 
elastic  chests,  the  heart  sounds  are  heard  with  greater  intensity 
than  in  older  persons  whose  chest  walls  are  thicker  and  stiffer. 
In  obese,  indolent  adults  it  is  sometimes  difficult  to  hear  any  heart 
sounds  at  all,  while  in  young  persons  of  excitable  temperament  the 
sounds  may  have  a  very  intense  and  ringing  quality.  Under  dis- 


AUSCULTATION  OF  THE  HEART.  175 

eased  conditions  either  of  the  heart  sounds  may  be  increased  or 
diminished  in  intensity.  I  shall  consider 

(1)  The  first  Sound  at  the  Apex  (sometimes  Called  the  Mitral  First 

Sound) 

(a)  Increase  in  the  length  or  intensity  of  the  first  sound  at  the 
apex  of  the  heart  occurs  in  any  condition  which  causes  the  heart 
to  act  with  unusual  degree  of  force,  such  as  bodily  or  mental  exer- 
tion, or  excitement.     In  the  earlier  stages  of  infectious  fevers  a 
similar  increase  in  the  intensity  of  this  sound  may  sometimes  be 
noted.     Hypertrophy  of  the  left  ventricle  sometimes  has  a  similar 
effect  upon  the  sound,  but  less  often  than  one  would  suppose,  while 
dilatation  of  the  left  ventricle,  contrary  to  what  one  would  suppose, 
is  not  infrequently  associated  with  a  loud,  forcible  first  sound  at 
the  apex.     In  mitral  stenosis  the  first  sound  is  usually  very  intense 
and  is  often  spoken  of  as  a  "  thumping  first  sound  "  or  as  a  "  sharp 
slap." 

(b)  Shortening  and  weakening  of  the  first  sound  at  the  apex. 
In  the  course  of  continued  fevers  and  especially  in  typhoid  fever 

the  granular  degeneration  which  takes  place  in  the  heart  muscle  is 
manifested  by  a  shortening  and  weakening  of  the  first  sound  at  the 
apex,  so  that  the  two  heart  sounds  come  to  seem  much  more  alike 
than  usual.  In  the  later  stages  of  typhoid,  the  first  sound  may 
become  almost  inaudible.  The  sharp  "valvular  "  quality,  which 
one  notices  in  the  first  apex  sound  under  these  conditions,  has  been 
attributed  to  the  fact  that  weakening  of  the  myocardium  has  caused 
a  suppression  of  one  of  the  two  elements  which  go  to  make  up  the 
first  sound,  namely,  the  muscular  element,  so  that  we  hear  only  the 
short,  sharp  sound  due  to  the  tautening  of  the  mitral  curtains. 
Chronic  myocarditis,  or  any  other  change  in  the  heart  wall  which 
tends  to  enfeeble  it,  produces  a  weakening  and  shortening  of  the 
first  sound  similar  to  that  just  described.  Simple  weakness  in  the 
mitral  first  sound  without  any  change  in  its  duration  or  pitch  may 
be  due  to  fatty  overgrowth  of  the  heart,  to  emphysema  or  pericar- 
dial  effusion  in  case  the  heart  is  covered  by  the  distended  lung  or 
by  the  accumulated  fluid.  Among  valvular  diseases  of  the  heart 


176  PHYSICAL  DIAGNOSIS. 

the  one  most  likely  to  be  associated  with  a  diminution  in  intensity 
of  the  first  apex  sound  is  mitral  regurgitation. 

(c)  Doubling  of  the  first  sound  at  the  apex. 

It  is  not  uncommon  in  healthy  hearts  to  hear  in  the  region  of 
the  apex  impulse  a  doubling  of  the  first  sound  so  that  it  may  be 
suggested  by  pronouncing  the  syllables  "turrupp  "  or  "trupp."  In 
health  this  is  especially  apt  to  occur  at  the  end  of  expiration.  In 
disease  it  is  associated  with  many  different  conditions  involving  an 
increase  in  the  work  of  one  or  the  other  side  of  the  heart.  It 
seems,  however,  to  be  unusually  frequent  in  myocarditis. 

(2)  Modifications  in  the  Second  Sounds  as  Heard  at  the  Base  of  the 

Heart. 

Physiological  Variations. — The  relative  intensity  of  the  pul- 
monic  second  sound,  when  compared  with  the  second  sound  heard 
in  the  conventional  aortic  area,  varies  a  great  deal  at  different  pe- 
riods of  life.  Attention  was  first  called  to  this  by  Vierordt,1  and 
it  has  of  late  years  been  recognized  by  the  best  authorities  on  dis- 
eases of  the  heart,  though  the  majority  of  current  text-books  still 
repeat  the  mistaken  statement  that  the  aortic  second  sound  is  always 
louder  than  the  pulmonic  second  in  health. 

The  work  of  Dr.  Sarah  K.  Creighton,  done  in  my  clinic  during 
the  summer  of  1899,  showed  that  in  90  per  cent  of  healthy  chil- 
dren under  ten  years  of  age,  the  pulmonic  second  sound  is  louder 
than  the  aortic.  In  the  next  decade  (from  the  tenth  to  the  twen- 
tieth year)  the  pulmonic  second  sound  is  louder  in  two-thirds  of 
the  cases.  About  half  of  207  cases,  between  the  ages  of  twenty  and 
twenty-nine,  showed  an  accentuation  of  the  pulmonic  second,  while 
after  the  thirtieth  year  the  number  of  cases  showing  such  accentu? 
tion  became  smaller  with  each  decade,  until  after  the  sixtieth  year 
we  found  an  accentuation  of  the  aortic  second  in  sixty-six  out  of  sixty- 
eight  case-s  examined.  These  facts  are  exhibited  in  tabular  form  in 

1  Vierordt:  "Die  Messung  der  Intensitat  der  Herztone"  (Tubingen, 
1885).  See  also  Hochsinger,  "Die  Auscultation  des  kindlichen  Herzens"; 
Gibson,  "Diseases  of  the  Heart"  (1898)  ;  Kosenbach,  "Diseases  of  the  Heart" 
(1900) ;  Allbutt,  "System  of  Medicine." 


AUSCULTATION  OF  THE  HEART. 


177 


Figs.  110  and  111  and  appear  to  show  that  the  relative  intensity  of 
the  two  sounds  in  the  aortic  and  pulinonic  arteries  depends  pri- 
marily upon  the  age  of  the  individual,  the  pulmonic  sound  predomi- 
nating in  youth  and  the  aortic  in  old  age,  while  in  the  period  of 
middle  life  there  is  relatively  little  discrepancy  between  the  two 


100%^- 
90  *X 

DECADES. 
0-9    i  10-19  j  20-29  j  30-39   40-49 

50-59 

i 
60-69  i  70-79 

\ 

SO  ^/ 

\ 

70%- 

TJ 

\ 

V 

m 

3) 

o 

m 

z 

\ 

1 

5 

\ 

\ 

20%- 
10%- 

\ 

V 

^\ 

V 

—  ^, 

-—100% 


80% 


-70% 


FIG.  110.— Showing  the  Per  Cent  of  Accentuated  Pulmonic  Second  Sound  in  Each  Decadti 

Based  on  1,000  cases. 

It  is,  therefore,  far  from  true  to  suppose  that  we  can  obtain  evi- 
dence of  a  pathological  increase  in  the  intensity  of  either  of  the 
second  sounds  at  the  base  of  the  heart  simply  by  comparing  it  with 
the  other.  Pathological  accentuation  of  the  pulmonic  second 
sound  must  mean  a  greater  loudness  of  this  sound  than  should 
be  expected  at  the  age  of  the  patient  in  question,  and  not  simply  a 
greater  intensity  than  that  of  the  aortic  second  sound.  The  same 
12 


178 


PHYSICAL  DIAGNOSIS. 


observation  obviously  applies  to  accentuation  of  the  aortic  second 
sound. 

Both  the  aortic  and  the  pulmonic  second  sounds  are  sometimes 


DECADES. 


O/    i                       .»    M-W   30-39]  40-49  [50-59    60-69    70-79 

—-100% 
—90% 
-snV 

/^ 

-** 

80  ox 

/ 

/ 

70  OX"— 

r 

j 

—  00^5 

V 

/ 

Fi 

1) 
O 

m 
z   

H 

D 

5  .... 

30%- 
20%- 
10%- 

/ 

KflOX" 

y 

T 

-40% 

ofiOX 

Z 

/ 

-—20% 

10  OX 

1 

/ 

1 

FIG.  111.— Showing  the  Per  Cent  of  Accentuated  Aortic  Second  Sound   iu   Each   Decade. 

Based  on  1,000  cases. 

very  intense  during  great  emotional  excitement  or  after  muscular 
exertion,  and  sometimes  without  any  obvious  cause. 

Pathological   Variations. 

A.  Accentuation  of  the  Pulmonic  Second  Sound. 

Pathological  accentuation  of  the  second  sound  occurs  especially 
in  conditions  involving  a  backing  up  of  blood  in  the  lungs,  such  as 
occurs  in  stenosis  or  insufficiency  of  the  mitral  valve,  or  in  obstruc 


AUSCULTATION  OF  THE  HEART.  179 

tive  disease  of  the  lungs  (emphysema,  bronchitis,  phthisis,  chronic 
interstitial  pneumonia).  Indirectly  accentuation  of  the  pulnionic 
second  sound  points  to  hypertrophy  of  the  right  ventricle,  since 
without  such  hypertrophy  the  work  of  driving  the  blood  through 
the  obstructed  lung  could  not  long  be  performed.  If  the  right  ven- 
tricle becomes  weakened,  the  accentuation  of  the  pulmonic  second 
sound  is  no  longer  heard. 

B.    Weakening  of  the  Pulmonic  Second  Sound. 

Weakening  of  the  pulmonic  second  sound  is  a  very  serious  symp- 
tom, sometimes  to  be  observed  in  cases  of  pneumonia  or  cardiac 
disease  near  death.  It  is  thus  a  very  important  indication  for 
prognosis. 

Pulmonary  stenosis  also  weakens  or  abolishes  the  second  sound. 

C.  Accentuation  of  the  Aortic  Second  Sound. 

I  have  already  shown  that  the  aortic  second  sound  is  louder 
than  the  cdkresponding  sound  in  the  pulmonary  area  in  almost  every 
individual  over  sixty  years  of  age  and  in  most  of  those  over  forty. 
A  still  greater  intensity  of  the  aortic  second  sound  occurs — 

(a)  In  nephritis,  arterio-sclerosis,  or  any  condition  which  in- 
creases arterial  tension  and  so  throws  an  increased  amount  of  work 
upon  the  left  ventricle.     Directly,  therefore,  a  pathologically  loud 
aortic  sound  points  to  increased  resistance  in  the   peripheral  ar- 
teries and  indirectly  to  hypertrophy  of  the  left  ventricle. 

(b)  A   similar   increase   in   the  intensity   of  the  aortic  second 
sound  occurs  in  aneurism  or  diffuse  dilatation  of  the  aortic  arch. 

D.   Dim  unit  Ion  in  th<'  Intensity  of  the  Aortic  Second  Sound. 

Whenever  the  "amount  of  blood  thrown  into  the  aorta  by  the 
contraction  of  the  left  ventricle  is  diminished,  as  is  the  case  espe- 
cially in  mitral  stenosis  and  to  a  lesser  degree  in  mitral  regurgita- 
tion,  the  aortic  second  sound  is  weakened  so  that  at  the  apex  it- 
may  be  inaudible.  A  similar  effect  is  produced  by  any  disease 
which  weakens  the  walls  of  the  left  ventricle,  such  as  fibrous  myo- 


180  PHYSICAL  DIAGNOSIS. 

carditis,  fatty  degeneration,  and  cloudy  swelling.  Relaxation  of 
the  peripheral  arteries  has  the  same  effect.  In  conditions  of  col- 
lapse the  aortic  second  sound  may  be  almost  or  quite  inaudible. 

la  persons  past  middle  life  the  second  sounds  are  often  louder 
in  the  third  or  fourth  interspace  than  in  the  second,  so  that  if  we 
listen  only  in  the  second  space  we  may  gain  the  false  impression  that 
the  second  sounds  are  feeble. 

Accentuation  of  both  the  second  sounds  at  the  base  of  the 
heart  may  occur  in  health  from  nervous  causes  or  when  the  lungs 
are  retracted  by  disease  so  as  to  uncover  the  conus  arteriosus  and 
the  aortic  arch.  Under  these  conditions  the  second  sound  may  be 
seen  and  felt  as  well  as  heard.  In  a  similar  way,  an  apparent  in- 
crease in  the  intensity  of  either  one  of  the  second  sounds  at  the 
base  of  the  heart  may  be  produced  by  a  retraction  of  one  or  the 
other  lung. 

Summary. — (1)  The  mitral  first  sound  is  increased  by  hyper- 
trophy or  dilatation  of  the  left  ventricle,  and  among  valvular  dis- 
eases especially  by  mitral  stenosis.  It  is  weakened  or  reduplicated 
by  parietal  disease  of  the  heart.  Any  of  these  changes  may  occur 
temporarily  from  physiological  causes. 

(2)  The  pulmonic  second  sound  is  usually  more  intense   than 
the  aortic  in  children  and  up  to  early  adult  life.     Later  the  aortic 
second  sound  predominates.     Pathological  accentuation  of  the  sec- 
ond pulmonic  sound  usually  points  to  obstruction  in  the  pulmonary 
circulation  (mitral  disease,  emphysema,  etc.).     Weakening  of  the 
pulmonic  second  means  failure  of  the  right  ventricle  and  is  serious. 

(3)  The  aortic  second  sound  is  increased  pathologically  by  any 
cause  which  increases  the  work  of  the  left  ventricle  (arteriosclero- 
sis, chronic  nephritis).     It  is  diminished  when  the  blood  stream, 
thrown  into  the  aorta  by  the  left  ventricle,  is  abnormally  small 
fmitral  disease,  cardiac  failure). 

(4)  Changes  in  the  tri cuspid  sounds  are  rarely  recognizable, 
while  changes  in  the  first  aortic  and  pulmonic  sounds  have  little 
practical  significance. 


AUSCULTATION  OF  THE  HEART.  181 

Modifications  in  the  Rhythm  of  the  Cardiac  Sounds. 

(1)  Whenever  the  walls  of  the  heart  are  greatly  weakened  by 
disease,    for  example,  in  the  later  weeks  of  a   case   of  typhoid 
fever,  the  diastolic  pause  of  the  heart  is  shortened  so  that  the  car- 
diac sounds  follow  each  other  almost  as  regularly  as  the  ticking  of 
a  clock;  hence  the  term  "tick-tack  heart."     As  this  rhythm  is  not 
unlike  that  heard  in  the  foetal  heart,  the  name  of  "  embryocardia  " 
is  sometimes  applied  to  it.     The  "  tick-tack  "  rhythm  may  be  heard 
in  any  form  of  cardiac  disease  after  compensation  has  failed,  or  in 
any  condition  leading  to  collapse. 

(2)  A  less  common  change  of  rhythm  is  that  produced  by  a 
shortening  of  the  interval  between  the  two  heart  sounds  owing  to 
an  incompleteness  of  the  contraction  of  the  ventricle.     This  change 
may  occur  in  any  disease  of  the  heart  when  compensation  fails. 

(3)  The  "  Ga^oj;,  Rhythm." — Shortening  of  the  diastolic  pause 
together  with  doubling  of  one  or  another  of  the  cardiac  sounds  re- 
sults in  our  hearing  at  the  apex  of  the  heart  three  sounds  instead 
of  two,  which  follow  each  other  in  a  rhythm  suggesting  the  hoof 
beats  of  a  galloping  horse.     Such  a  rhythm  may  occur  temporarily  in 
any  heart  which  is  excited  or  overworked  from  any  cause,  but  when 
permanent  is  usually  a  sign  of  grave  cardiac-  weakness.     The  rhythms 
so  produced  are  usually  anapaestic,  ^  ^ — ',  ^  ^ — ',  ^->^ — ',  or  of 
this  type :  ^  — '  ^,  ^  — '  -^,  ^  —  ^. 

Doubling  of  the  Second  Sounds  at  the  Base  of  the  Heart. — At 
the  end  of  a  long  inspiration  this  change  may  be  observed  in  al- 
most any  healthy  person  if  one  listens  at  the  base  of  the  heart.  It 
is  still  better  brought  out  after  muscular  exertion  or  by  holding  the 
breath.  In  such  cases  it  probably  expresses  the  non-synchronous 
closure  of  the  aortic  and  pulmonic  valves,  owing  to  increased  press- 
ure in  the  pulmonary  circulation.  Similarly  in  diseased  condi- 
tions, anything  which  increases  the  pressure  either  in  the  periph- 
eral arteries  or  in  the  pulmonary  circulation,  and  thus  throws 
increased  work  upon  one  or  the  other  ventricle,  will  cause  a  doub- 
ling of  the  second  sound  as  heard  at  the  base  of  the  heart. 

In  mitral  stenosis  a  double   diastolic   sound  is  usually  to  to3 


182  PHYSICAL  DIAGNOSIS. 

heard  at  the  apex,  and  in  the  diagnosis  of  this  disease  this  "  double 
shock  sound "  during  diastole  may  be  an  important  piece  of  evi- 
dence, and  may  sometimes  be  felt  as  well  as  heard.  The  "  double 
shock  sound  "  of  mitral  stenosis  is  not  generally  believed  to  repre- 
sent a  doubling  of  the  ordinary  second  sound,  although  it  corre- 
sponds with  diastole.  Just  what  its  mechanism  is,  is  disputed. 

I  have  said  nothing  about  modifications  in  the  second  sound  at 
the  apex,  since  this  sound  is  now  generally  agreed  to  represent  the 
aortic  second  sound  transmitted  by  the  left  "ventricle  to  the  apex. 
The  first  sounds  at  the  base  of  the  heart  have  also  not  been  dwelt 
upon,  since  they  have  no  special  importance  in  diagnosis. 

Metallic  Heart  Sounds. 

The  presence  of  air  in  the  immediate  vicinity  of  the  heart, 
as,  for  example,  in  pneumothorax  or  in  gaseous  distention  of  the 
stomach  or  intestine,  may  impart  to  the  heart  sounds  a  curious 
metallic  quality  such  as  is  not  heard  under  any  other  conditions. 

"Muffling,"  "Prolongation,"  or  "  Unclearness"  of  the  Heart  Sounds. 

These  terms  are  not  infrequently  met  with  in  literature,  but 
their  use  should,  I  think,  be  discontinued.  The  facts  to  which 
they  refer  should  be  explained  either  as  faintness  of  the  heart 
sounds,  due  to  the  causes  above  assigned,  or  as  faint,  short  mur- 
murs. In  their  present  usage  such  terms  as  "  muffled  "  or  "  unclear  " 
heart  sounds  represent  chiefly  an  unclearness  in  the  mind  of  the 
observer  as  to  just  what  it  is  that  he  hears,  and  not  any  one  recog- 
nized pathological  condition  in  the  heart. 

IV.  SOUNDS  AUDIBLE  OVER  THE  PERIPHERAL  VESSELS. 

(1)  The  normal  heart  sounds  are  in  adults    audible  over  the 
carotids  and  over  the  subclavian  arteries.     In  childhood  and  youth 
only  the  second  heart  sound  is  thus  audible. 

(2)  In  about  7  per  cent  of  normal  persons  a  systolic  sound  can 
be  heard  over  the  femoral  artery.     This  sound  is  obviously  not 


AUSCULTATION  OF  THE  HEART.  183 

transmitted  from  the  heart,  and  is  usually  explained  as  a  result  of 
the  sudden  systolic  tautening  of  the  arterial  wall. 

In  aortic  re  gurgitation  this  arterial  sound  is  almost  always 
audible  not  only  in  the  femoral  but  in  the  brachial  and  even  in  the 
radial,  and  its  intensity  over  the  femoral  becomes  so  great  that  the 
term  "pistol-shot"  sound  has  been  applied  to  it.  In  fevers, 
exophthalmic  goitre,  lead  poisoning,  and  other  diseases,  a  similar 
arterial  sound  is  to  be  heard  much  more  frequently  than  in  health. 

Venous  Sounds. 

The  violent  closure  of  the  venous  valves  in  the  jugular  is  some- 
times audible  in  cases  of  insufficiency  of  the  tricuspid  valve.  The 
sound  has  no  clinical  importance,  and  is  difficult  to  distinguish  owing 
to  the  presence  of  the  carotid  first  sound  mentioned  above. 


CHAPTER  IX 

AUSCULTATION  OP  THE  HEART:  CONTINUED. 

CARDIAC  MURMURS. 

(a)  Terminology. 

THE  word  "  murmur  "  is  one  of  the  most  unfortunate  of  all  the 
terms  used  in  the  description  of  physical  signs.  No  one  of  the 
various  blowing,  whistling,  rolling,  rumbling,  or  piping  ncises  to 
which  the  term  refers,  sounds  anything  like  a  " murmur "  in  the 
ordinary  sense  of  the  word.  Nevertheless,  it  does  not  seem  best 
to  try  to  replace  it  by  any  other  term.  The  French  word  "  souffle  " 
is  much  more  accurate  and  has  become  to  some  extent  Anglicized. 
Under  the  head  of  cardiac  murmurs  are  included  all  abnormal 
sounds  produced  within  the  heart  itself.  Pericardial  friction 
sounds  and  those  produced  in  that  portion  of  the  lung  or  pleura 
which  overlies  the  heart  are  not  considered  "murmurs." 

(ti)  Mode  of  Production. 

With  rare  exceptions  all  cardiac  murmurs  are  produced  at  or 
near  one  of  the  valve  orifices,  either  by  disease  of  the  valves  them- 
selves resulting  in  shrivelling,  thickening,  stiffening,  and  narrowing 
of  the  valve  curtains,  or  by  a  stretching  of  the  orifice  into  which 
the  valves  are  inserted. 

Diseases  of  the  valves  themselves  may  lead  to  the  production  of 
murmurs : 

(a)  When  the  valves  fail  to  close  at  the  proper  time  (incompe- 
tence, insufficiency,  or  regurgitation). 

(b)  When  the  valves  fail  to  open  at  the  proper  time  (stenosis 
or  obstruction) . 


AUSCULTATION  OF  THE  HEART.  185 

(c)  When  the  surfaces  of  the  valves  or  of  the  parts  immedi- 
ately adjacent  are  roughened  so  as  to  prevent  the  smooth  flow  of  the 
blood  over  them. 

(d]  When  the  orifice  which  the  valves  are  meant  to  close  is  di- 
lated as  a  result  of  dilatation  of  the  heart  chamber  of  which  it  forms 


FIG.  112.— Diagram  to  Illustrate  the  Production  of  a  Cardiac  Murmur  Through  Regurgltation 
from  the  Aorta  or  in  an  Aneurismal  Sac.  The  arrow  shows  the  direction  of  the  blood  cur- 
rent and  the  curled  lines  the  audible  blood  eddies. 

the  entrance  or  exit.  The  valves  themselves  cannot  enlarge  to 
keep  pace  with  the  enlargement  of  the  orifice,  and  hence  no  longer 
suffice  to  reach  across  it. 

The  presence  of  any  one  of  these  lesions  gives  rise  to  eddies 
in  the  blood  current  and  thereby  to  the  abnormal  sounds  to  which 
we  give  the  name  murmurs.1  (See  Figs.  112, 113  and  114.)  When 


Kiii.  li:j.    Diagram  to  Illustrate  the  Production  of  a  Cardiac  Murmur  Through  Stenosis  of  e 

Valve-Oriflce. 

valves  fail  to  close  and  so  allow  the  blood  to  pass  back  through 
them,  we  speak  of  the  lesion  as  regurgitation,  insufficiency,  or  in- 
competence;  if,  for  example,  the  aortic  valves  fail  to  close  after 
the  ]eft  ventricle  has  thrown  a  column  of  blood  into  the  aorta, 
some  of  this  blood  regurgitates  through  these  valves  into  the  ven- 

1  The  method  by  which  functional  murmurs  are  produced  will  be  discussed 
later.     (See  page  194.) 


186  PHYSICAL  DIAGNOSIS. 

tricle  from  which  it  has  just  been  expelled,  and  we  speak  of  the 
lesion  as  "aortic  regurgitation,"  and  of  the  murmur  so  produced  as 
an  aortic  regurgitant  murmur  or  a  murmur  of  aortic  regurgitation. 
A  similar  regurgitation  from  the  left  ventricle  into  the  left  auricle 
takes  place  in  case  the  mitral  valve  fails  to  close  at  the  beginning 
of  systole.  If,  on  the  other  hand,  the  mitral  valve  fails  to  open 
properly  to  admit  the  blood  which  should  flow  during  diastole  from 
the  left  auricle  into  the  left  ventricle,  we  speak  of  the  condition  as 
mitral  stenosis  or  mitral  obstruction.  A  similar  narrowing  of  the 
aortic  valves  such  as  to  hinder  the  egress  of  blood  during  the  systole 
of  the  left  ventricle  is  known  as  aortic  stenosis  or  obstruction.  Val- 


f  IG.  114.— Diagram  to  Illustrate  the  Production  of  Cardiac  Murmurs  Through  Roughening  of  a 

Valve. 

vular  lesions  of  the  right  side  of  the  heart  (tricuspid  and  pulmonic 
valves)  are  comparatively  rare,  but  are  produced  and  named  in  a 
way  similar  to  those  just  described. 

The  facts  most  important  to  know  about  a  murmur  are : 

(1)  Its  place  in  the  cardiac  cycle. 

(2)  Its  point  of  maximum  intensity. 

(3)  The  area  over  which  it  can  be  heard. 

(4)  The  effects  of  exertion,  respiration,  or  position  upon  it. 
Less  important  than  the  above  are : 

(5)  Its  intensity. 

(6)  Its  quality. 

(7)  Its  length. 

(8)  Its  relation  to  the  normal  sounds  of  the  heart. 
Each  of  these  points  will  now  be  taken  up  in  detail : 

(1)  Time  of  Murmurs. — The  first  and  most  important  thing  to 
iscertain  regarding  a  murmur  is  its  relation  to  the  normal  cardiac 
cycle ;  that  is,  whether  it  occurs  during  systole  or  during  diastole, 
or  in  case  it  does  not  fill  the  whole  of  one  of  those  periods,  in  what 


AUSCULTATION  OF  THE  HEART.  187 

part  of  systole  or  diastole  it  occurs.  It  must  be  borne  in  mind  that 
the  period  of  systole  is  considered  as  lasting  from  the  beginning  of 
the  first  sound  of  the  heart  up  to  the  occurrence  of  the  second 
sound,  while  diastole  lasts  from  the  beginning  of  the  second  sound 
until  the  beginning  of  the  first  sound  in  the  next  cycle.  Any  mur- 
mur occurring  with  the  first  sound  of  the  heart,  or  at  the  time  when 
the  first  sound  should  take  place,  or  in  any  part  of  the  period  inter- 
vening between  the  first  sound  and  the  second,  is  held  to  be  systolic, 
Murmurs  which  distinctly  follow  the  first  sound  or  do  not  begin 
until  the  first  sound  is  ended  are  known  as  late  systolic  murmurs. 

On  the  other  hand,  it  seems  best,  for  reasons  to  be  discussed 
more  in  detail  later  on,  not  to  give  the  name  of  diastolic  to  all 
murmurs  which  occur  within  the  diastolic  period  as  above  defined. 
Murmurs  which  occur  during  the  last  part  of  diastole  and  which 
run  up  to  the  first  sound  of  the  next  cycle  are  usually  known  as 
" presystolic  "  murmurs.  All  other  murmurs  occurring  during  dias- 
tole are  known  as  diastolic. 

The  commonest  of  all  the  errors  in  the  diagnosis  of  disease  of 
the  heart  is  to  mistake  systole  for  diastole,  and  thereby  to  misin- 
terpret the  significance  of  a  murmur  heard,  during  those  periods. 
This  mistake  would  never  happen  if  we  were  always  careful  to 
make  sure,  by  means  of  sight  or  touch,  just  when  the  systole  of 
the  heart  occurs.  This  may  be  done  by  keeping  one  finger  upon 
the  apex  impulse  of  the  heart  or  upon  the  carotid  artery  while 
listening  for  murmurs,  or,  in  case  the  apex  impulse  or  the  pulsa- 
tions of  the  carotid  are  better  seen  than  felt,  we  can  control  by  the 
eye  the  impressions  gained  by  listening.  It  is  never  safe  to  trust 
our  appreciation  of  the  cardiac  rhythm  to  tell  us  which  is  the  first 
heart  sound  and  which  the  second.  The  proof  of  this  statement 
is  given  by  the  numberless  mistakes  made  through  disregarding  it. 
Equally  untrustworthy  as  a  guide  to  the  time  of  systole  and  dias- 
tole is  the  radial  pulse,  which  follows  the  cardiac  systole  at  an 
interval  just  long  enough  to  mar  our  calculations. 

(2)  Localizations  of  Murmurs. — To  localize  a  murmur  is  to  find 
its  point  of  maximum  intensity,  and  this  is  of  the  greatest  impor- 
tance in  diagnosis.  Long  experience  has  shown  that  murmurs 


188  PHYSICAL  DIAGNOSIS. 

V- 

heard  loudest  in  the  region  of  the  apex  beat  (whether  this  is  in  the 
normal  situation  or  displaced),  are  in  the  vast  majority  of  cases  pro- 
duced at  the  mitral  valve.  In  about  five  per  cent  of  the  cases  mitral 
murmurs  may  be  best  heard  at  a  point  midway  between  the  position 
of  the  normal  cardiac  impulse  and  the  ensiform  cartilage,  or  (rarely) 
an  inch  or  two  above  this  situation. 

Murmurs  heard  most  loudly  in  the  second  left  intercostal  space 
are  almost  invariably  produced  at  the  pulmonic  orifice  or  just  above 
it  in  the  conus  arteriosus. 

Murmurs  whose  maximum  intensity  is  at  the  root  of  the  ensi- 
form cartilage  or  within  a  radius  of  an  inch  and  a  half  from  this 
point  are  usually  produced  at  the  tri cuspid  orifice.  Murmurs  pro- 
duced at  the  aortic  orifice  may  be  heard  best  in  the  aortic  area,  but 
in  a  large  proportion  of  cases  are  loudest  on  the  other  side  of  the 
sternum  at  or  about  the  situation  of  the  fourth  left  costal  cartilage. 
Occasionally  they  are  best  heard  at  the  apex  of  the  heart  in  the 
axilla  or  over  the  lower  part  of  the  sternum  (see  below,  Fig.  137). 

(3)  Transmission  of  Murmurs.  — If  a  murmur  is  audible  over  sev- 
eral valve  areas,  the  questions  naturally  arise:  "How  are  we  to 
know  whether  we  are  dealing  with  a  single  valve  lesion  or  with 
several?  Is  this  one  murmur  or  two  or  three  murmurs?  "  Obvi- 
ously the  question  can  be  asked  only  in  case  the  murmur  which  we 
find  audible  in  various  places  occupies  everywhere  the  same  time 
in  the  cardiac  cycle.  It  must,  for  example,  be  everywhere  systolic 
or  everywhere  diastolic.  A  systolic  murmur  at  the  apex  cannot 
be  supposed  to  point  to  the  same  lesion  as  a  diastolic  murmur,  no 
matter  where  the  latter  is  heard.  But  if  we  hear  a  systolic  mur- 
mur in  various  parts  of  the  chest,  say  over  the  aortic,  mitral,  and 
tricuspid  regions,  how  are  we  to  know  whether  the  sound  is  simple 
or  compound,  whether  produced  at  one  valve  orifice  or  at  several? 

This  question  is  sometimes  difficult  to  answer,  and  in  a  given 
case  skilled  observers  may  differ  in  their  verdict,  but,  as  a  rule,  the 
difficulty  may  be  overcome  as  follows : 

(1)  Experience  and  post-mortem  examination  have  shown  that 
the  murmur  produced  by  each  of  the  valvular  lesions  has  its  own 
characteristic  area  of  propagation,  over  which  it  is  heard  with  an  in- 


AUSCULTATION  OF  THE  HEART. 


189 


tensity  which  regularly  diminishes  as  we  recede  from  a  maximum 
whose  seat  corresponds  with  some  one  of  the  valve  areas  just  de- 
cribed.  These  areas  of  propagation  are  shown  in  Figs.  125,  126,  129, 
and  134.  Any  murmur  whose  distribution  does  not  extend  beyond 
one  of  these  areas,  and  which  steadily  and  progressively  diminishes 
in  intensity  as  we  move  away  from  the  valve  area  over  which  it  is 
loudest^  may  be  assumed  to  be  due  to  a  single  valve  lesion  and  no 


FIG.  115.— Mitral  and  Tricuspid  Uegurgitation.    The  intensity  of  the  systolic  murmur  is  least  at 
the  "  waist "  of  the  shaded  area  and  increases  as  one  approaches  either  end  of  it. 

more.     Provided  but  one  valve  is  diseased,  this  course  of  procedure 
gives  satisfactory  results. 

(2)  When  several  valves  are  diseased  and  several  murmurs  may 
be  expected,  it  is  best  to  start  at  some  one  valve  area,  say  hi  the 
mitral  or  apex  region,  and  move  the  stethoscope  one-half  an  inch 
at  a  time  toward  one  of  the  other  valve  areas,  noting  the  intensity 
of  any  murmur  we  may  hear  at  each  of  the  different  points  passed 
over.  As  we  move  toward  the  tricuspid  area,  we  may  get  an  im- 
pression best  expressed  by  Fig.  115.  That  is,  a  systolic  murmur 
beard  loudly  at  the  apex  may  fade  away  as  we  move  toward  the 
ensiform,  until  at  the  point  x  (Fig.  115)  it  is  almost  inaudible.  Hut 
as  \vo  go  on  in  the  same  direction  the  murmur  i.iay  begin  to  grow 


190  PHYSICAL  DIAGNOSIS. 

louder  (and  perhaps  to  change  in  pitch  and  quality  as  well)  until  a 
maximum  is  reached  at  the  tricuspid  area,  beyond  which  the  mur- 
mur again  fades  out. 

These  facts  justify  us  in  suspecting  that  we  are  dealing  with  two 
murmurs,  one  produced  at  the  tricuspid  and  one  at  the  mitral  ori- 
fice. The  suspicion  is  more  likely  to  be  correct  if  there  has  been 
a  change  in  the  pitch  and  quality  of  the  murmur  as  we  neared  the 
tricuspid  orifice,  and  may  be  confirmed  by  the  discovery  of  other 
evidences  of  a  double  lesion.  JVb  diagnosis  is  satisfactory  which 
rests  on  the  evidence  of  murmurs  alone.  Changes  in  the  size  of 
the  heart's  chambers  or  in  the  pulmonary  or  peripheral  circulations 
are  the  most  important  facts  in  the  case.  Nevertheless  the  effort 
to  ascertain  and  graphically  to  represent  the  intensity  of  cardiac 
murmurs  as  one  listens  along  the  line  connecting  the  valve  areas 
has  its  value.  An  "hour-glass  "  murmur,  such  as  that  represented 
in  Fig.  115),  generally  means  two-valve  lesions.  A  similar  "hour- 
glass "  may  be  found  to  represent  the  auditory  facts  as  we  move 
from  the  mitral  to  the  pulmonic  or  to  the  aortic  areas  (see  Fig. 
116)  and,  as  in  the  previous  case,  arouses  our  suspicion  that  more 
than  one  valve  is  diseased. 

It  must  not  be  forgotten,  however,  that  "  a  murmur  may  travel 
some  distance  underground  and  emerge  with  a  change  of  quality  " 
(Allbutt).  This  is  especially  true  of  aortic  murmurs,  which  are  often 
heard  well  at  the  apex  and  at  the  aortic  area,  and  faintly  in  the  in- 
tervening space,  probably  owing  to  the  interposition  of  the  right, 
ventricle. 

In  such  cases  we  must  fall  back  upon  the  condition  of  the  heart 
itself,  as  shown  by  inspection,  palpation,  and  percussion,  and  upon 
the  condition  of  the  pulmonary  and  peripheral  circulation,  as 
shown  in  the  other  symptoms  and  signs  of  the  cases  (dropsy,  cough, 
etc.). 

(4)  Intensity  of  Murmurs. — Sometimes  murmurs  are  so  loud 
that  they  are  audible  to  the  patient  himself  or  even  at  some  dis- 
tance from  the  chest.  In  one  case  ,1  was  able  to  hear  a  murmur 
eight  feet  from  the  patient.  Such  cases  are  rare  and  usually  not 
serious,  for  the  gravity  of  the  lesion  is  not  at  all  proportional  to 


AUSCULTATION  OF  THE  HEART. 


191 


the  loudness  of  the  murmur;  indeed,  other  things  being  equal, 
loud  murmurs  are  less  serious  than  faint  ones,  provided  we  are  sure 
we  are  dealing  with  organic  lesions.  (On  the  distinction  between 
the  organic  and  functional  murmurs,  see  below,  p.  196. ) 

A  loud  murmur  means  a  powerful  heart  driving  the  blood 
strongly  over  the  diseased  valve.  When  the  heart  begins  to  fail, 
the  intensity  of  the  murmur  proportionately  decreases  because  the 
blood  does  not  flow  swiftly  enough  over  the  diseased  valve  to  pro- 


FIG.  116.— Mitral  Repurgitation  and  Aortic  Stenosis.    The  systolic  murmur  is  loudest  at  the  ex- 
tremities of  the  shaded  area  and  faintest  at  its  "  waist." 

duce  as  loud  a  sound  as  formerly.  The  gradual  disappearance  of 
a  murmur  known  to  be  due  to  a  valvular  lesion  is,  therefore,  a  very 
grave  sign,  and  its  reappearance  revives  hope.  Patients  are  not 
infrequently  admitted  to  a  hospital  with  valvular  heart  trouble 
which  has  gone  on  so  long  that  the  muscle  of  the  heart  is  no  longer 
strong  enough  to  produce  a  murmur  as  it  pumps  the  blood  over  the 
diseased  valve.  In  such  a  case,  under  the  influence  of  rest  and 
cardiac  tonics,  one  may  observe  the  development  of  a  murmur  as 
the  heart  wall  regains  its  power,  and  the  louder  the  murmur  be- 
comes the  better  the  condition  of  the  patient.  On  the  other  hand, 
when  the  existence  of  a  valvular  lesion  has  been  definitely  deter 


192  PHYSICAL  DIAGNOSIS. 

mined,  and  yet  the  compensation  remains  perfectly  good  (for  exam 
pie,  in  the  endocarditis  occurring  in  children  in  connection  with 
chorea) ,  an  increase  in  the  loudness  of  the  murmur  may  run  paral- 
lel with  the  advance  in  the  valvular  lesion. 

In  general  the  most  important  point  about  the  intensity  of  a 
murmur  is  its  increase  or  decrease  while  under  observation,  and  not 
its  loudness  at  any  one  time. 

(5)  Quality  of  Heart  Murmurs.  — It  has  been  alre'ady  mentioned 
that  the  quality  of  a  heart  murmur  is  never  anything  like  the 
sound  which  we  ordinarily  designate  by  the  word  "  murmur. "  The 
commonest  type  of  heart  murmur  has  a  blowing  quality,  whence  the 
old  name  of  "bellows  sound."  The  sound  of  the  letter  "f "  pro- 
longed is  not  unlike  the  quality  of  certain  murmurs.  Blowing 
murmurs  may  be  low-pitched  like  the  sound  of  air  passing  through 
a  large  tube,  or  high-pitched  approaching  the  sound  of  a  whistle. 
This  last  type  merges  into  that  known  as  the  musical  murmur,  in 
which  there  is  a  definite  musical  sound  whose  pitch  can  be  identi- 
fied. Rasping  or  tearing  sounds  often  characterize  the  louder 
varieties  of  murmurs. 

Finally,  there  is  one  type  of  sound  which,  though  included 
under  the  general  name  murmur,  differs  entirely  from  any  of  the 
other  sounds  just  described.  This  is  the  "presystolic  roll,"  which 
has  a  rumbling  or  blubbering  quality  or  may  remind  one  of  a  short 
drum-roll.  This  murmur  is  always  presystolic  in  time  and  usually 
associated  with  obstruction  at  the  mitral  or  tricuspid  valves.  Not 
infrequently  some  part  of  a  cardiac  murmur  will  have  a  musical 
quality  while  the  rest  is  simply  blowing  or  rasping  in  character. 
Musical  murmurs  do  not  give  us  evidence  either  of  an  especially 
serious  or  especially  mild  type  of  disease.  Their  chief  importance 
consists  in  the  fact  that  they  rarely  exist  without  some  valve 
lesion,1  and  are,  therefore,  of  use  in  excluding  the  type  of  mur- 
mur known  as  "functional,"  presently  to  be  discussed,  and  not 
due  to  valve  disease.  Very  often  rasping  murmurs  are  associated 
either  with  the  calcareous  deposit  upon  a  valve  or  very  marked 
narrowing  of  the  valve  orifice. 

1  Kosenbach  holds  that  they  may  be  produced  by  adhesive  pericarditis 


AUSCULTATION  OF  THE  HEART,  193 

Murmurs  may  be  accented  at  the  beginning  or  the  end;  that  is. 
they  ma/  be  of  the  crescendo  type,  growing  louder  toward  the  end. 
or  of  the  decrescendo  type  with  their  maximum  intensity  at  the 
beginning.  Almost  all  murmurs  are  of  the  latter  type  except  those 
associated  with  mitial  or  tricuspid  obstruction. 

(6)  Length  of  Murmurs. — Murmurs  may  occupy  the  whole 
of  systole,  the  whole  of  diastole,  or  only  a  portion  of  one  of 
these  periods,  but  no  conclusions  can  be  drawn  as  to  the  severity 
of  the  valve  lesion  from  the  length  of  the  murmur.  A  short  mur- 
mur, especially  if  diastolic,  may  be  of  very  serious  prognostic  im- 
port. 

(7)  Relations  to  the  Normal  Sounds  of  the  Heart. — Cardiac  mur- 
murs may  or  may  not  replace  the  normal  heart  sounds.     They  may 
occur    simultaneously  with    one  or  both  sounds  or  between   the 
counds.     These  facts  have  a  certain  amount  of  significance  in  prog- 
nosis.    Murmurs  which  entirely  replace  cardiac  sounds  usually  mean 
a  severer  disease  of  the  affected  valve  than  murmurs  which  accom- 
pany, but  do  not  replace,  the  normal  heart  sounds.     Late  systolic 
murmurs,  which  occur  between  the  first  and  the  second  sound,  are 
usually  associated  with  a  relatively  slight  degree  of  valvular  dis- 
ease.    Late  diastolic  murmurs,  on  the  other  hand,  have  no  such 
favorable  significance. 

(8)  Effects  of  Position,  Exercise,  and  Respiration  upon  Cardiac 
Murmurs. — Almost  all  cardiac  murmurs  are  affected  to  a  greater 
or  less  extent  by  the  position  which  the  patient  assumes  while  he 
is  examined.     Systolic   murmurs  which   are   inaudible  while  the 
patient  is  in  a  sitting  or  standing  position  may  be  quite  easily 
heard  when  the  patient  lies  down.     On  the  other  hand,  a  pre- 
systolic  roll  which  is  easily  heard  when  the  patient  is  sitting  up 
may  entirely  disappear  when  he  lies  down.      Diastolic  murmurs 
are  relatively  little  affected  by  the  position  of  the    patient,  but 
in  the  majority  of  cases  are  somewhat  louder  in  the  upright  posi- 
tion. 

The  effects  of  exercise  may  perhaps  be  fitly  mentioned  here. 
Feeble  murmurs  may  altogether  disappear  when  the  patient  is  at 
vest,  and  under  such  circumstances  may  be  made  easily  audible  by 
13 


194  PHYSICAL  DIAGNOSIS. 

getting  the  patient  to  walk  briskly  up  and  down  the  room  a  few 
times.  Such  lesions  are  usually  comparatively  slight.1  On  the 
other  hand,  murmurs  which  become  more  marked  as  a  result  of  rest 
are  generally  of  the  severest  type  (see  above,  p.  190). 

Organic  murmurs  are  usually  better  heard  at  the  end  of  expira- 
tion and  become  fainter  during  inspiration  as  the  expanding  lung 
covers  the  heart.  This  is  especially  true  of  those  produced  at  the 
mitral  valve,  and  is  in  marked  contrast  with  the  variations  of  func- 
tional murmurs  which  are  heard  chiefly  or  exclusively  at  the  end  of 
inspiration. 

(9)  Sudden  Metamorphosis  of  Murmurs. — In  acute  endocarditis, 
when  vegetations  are  rapidly  forming  and  changing  their  shape 
upon  the  valves,  murmurs  may  appear  and  disappear  very  sud- 
denly. This  metamorphosing  character  of  cardiac  murmurs,  when 
taken  in  connection  with  other  physical  signs,  may  be  a  very  im- 
portant factor  in  the  diagnosis  of  acute  endocarditis.  In  a  similar 
way  relaxation  or  rupture  of  one  of  the  tendinous  cords,  occurring 
hi  the  course  of  acute  endocarditis,  may  effect  a  very  sudden  change 
in  the  auscultatory  phenomena. 

"Functional  Murmurs." 

Not  every  murmur  which  is  to  be  heard  over  the  heart  points  to 
disease  either  in  the  valves  or  in  the  orifices  of  the  heart.  Perhaps 
the  majority  of  all  murmurs  are  thus  unassociated  with  valvular 
disease,  and  to  such  the  name  of  "accidental,"  "functional,"  or 
"  hsemic  "  murmurs  has  been  given.  The  origin  of  these  "  functional " 
murmurs  has  given  rise  to  an  immense  amount  of  controversy,  and 
it  cannot  be  said  that  any  one  explanation  is  now  generally  agreed 
upon.  To  me  the  most  plausible  view  is  that  which  regards  most 
of  them  as  due  either  to  a  temporary  or  permanent  dilatation  of 
the  conus  arteriosus,  or  to  pressure  or  suction  exerted  upon  the 
overlapping  lung  margins  by  the  cardiac  contractions.  This  ex- 
plains only  the  systolic  functional  murmurs,  which  make  up  ninety- 
nine  per  cent,  of  all  functional  murmurs.  The  diastolic  functional 
murmurs,  which  undoubtedly  occur,  although  with  exceeding  rarity, 
J  For  exception  to  this  see  below,  page  215. 


AUSCULTATION  OF  THE  HEART,  195 

are  probably  due  to  stretching  of  the  aortic  ring  or  to  sounds  pro- 
duced in  the  veins  of  the  neck  and  transmitted  to  the  vena  cava. 

Characteristics  of  Functional  Murmurs. — (1)  Almost  all  func- 
tional murmurs  are  systolic,  as  has  before  been  mentioned. 

(2)  The  vast  majority  of  them  are  heard  best  over  the  pulmonic 
valve  in  the  second  left  intercostal  space.     From  this  point  they 
are  transmitted  in  all  directions,  and  are  frequently  to  be  heard,  al- 
though with  less  intensity,  in  the  aortic  and  mitral  areas.     Occa- 
sionally they  may  have  their  maximum  intensity  in  one  of  the  latter 
positions. 

(3)  As  a  rule,  they  are  very  soft,  short,  and  blowing  in  quality, 
though  exceptionally  they  may  be  loud  and  rough. 

(4)  They  are  not  associated  with  any  evidence  of  enlargement 
of  the  heart  nor  with  accentuation  of  the  pulmonic  second  sound.1 

(5)  They  are  usually  louder  at  the  end  of  inspiration. 

(6)  They  are  usually  heard  over  a  very  limited  area  and  not 
transmitted  to  the  left  axilla  or  to  the  back. 

(7)  They  are  especially  evanescent  in  character ;  for  example, 
they  may  appear  at  the  end  of  a  hard  run  or  boat  race  or  during 
an  attack  of  fever,  and  disappear  within  a  few  days  or  hours.    Res- 
piration, position,  and  exercise  produce  greater  variations  in  them 
than  in  "  organic  "  murmurs. 

(8)  They   are   especially   apt   to  be  associated  with   anaemia, 
although  the  connection  between  anaemia  and  functional  heart  mur- 
murs is  by  no  means  as  close  as  has  often  been  supposed.     The 
severest  types  of  anaemia,  for  example  pernicious  anaemia,  may  not 
be  accompanied  by  any  murmur,  while,  on  the  other  hand,  typical 
functional  murmurs  are  often  heard  in  patients  whose  blood  is  nor- 
mal, and  even  in  full  health.     Yet  in  three  cases  of  intense  anaemia 
I  have  heard  diastolic  murmurs  loudest  at  the  fourth  left  costal  car- 
tilage and  leading  to  a  diagnosis  of  aortic  regurgitation.     At  au- 
topsy the  aortic  valves  were  in  each  case  sound,  and  I  am  at  a  loss 

1  In  chlorosis  the  second  pulmonic  sound  is  often  very  loud  (owing  to  the 
retraction  of  the  lungs  and  uncovering  of  the  conus  arteriosus)  and  associated 
with  a  systolic  murmur. 


196  PHYSICAL  DIAGNOSIS. 

to  account  for  the  murmurs.'  It  should  not  be  forgotten  that  a 
real,  though  temporary,  leakage  through  the  mitral  or  tricuspid 
valve  may  be  associated  with  anaemia  or  debilitated  conditions 
owing  to  weakening  of  the  papillary  muscles  or  of  the  mitral 
sphincter.  In  such  cases  we  find  not  the  signs  of  a  functional 
murmur,  as  above  described,  but  the  evidence  of  an  organic  valve 
lesion  hereafter  to  be  described. 

The  distinctions  between  organic  and  functional  heart  murmurs 
may  be  summed  up  as  follows : 

Organic  murmurs  may  occupy  any  part  of  the  cardiac  cycle ;  if 
systolic,  they  are  usually  transmitted  either  into  the  axilla  and 
back  or  into  the  great  vessels  of  the  neck ;  they  are  usually  asso- 
ciated with  evidences  of  cardiac  enlargement  and  changes  in  the  sec- 
ond sounds  at  the  base  of  the  heart,  as  well  as  with  signs  and  symp- 
toms of  stasis  in  other  organs.  Organic  murmurs  not  infrequently 
have  a  musical  or  rasping  quality,  although  this  is  by  no  means  al- 
ways the  case.  They  are  rarely  loudest  in  the  pulmonic  area  and 
are  relatively  uninfluenced  by  respiration,  position,  or  exercise. 

Functional  murmurs  are  almost  always  systolic  in  time  and 
usually  heard  with  maximum  intensity  in  the  pulmonic  area.  They 
are  rarely  transmitted  beyond  the  precordial  region  and  are  usually 
loudest  at  the  end  of  inspiration.  They  are  not  accompanied  by 
evidences  of  cardiac  enlargement  or  pathological  accentuation  of 
the  second  sounds  at  the  base  of  the  heart,  nor  by  signs  of  venous 
stasis  or  dropsy.  They  are  very  apt  to  be  associated  with  anaemia 
or  with  some  special  attack  upon  the  resources  of  the  body  (e.g., 
physical  overstrain  or  fever),  and  to  disappear  when  such  forces  are 
removed.  They  are  usually  soft  in  quality ;  never  musical.  The 
very  rare  diastolic  functional  murmur  occurs  exclusively,  so  far  as 
I  am  aware,  in  conditions  of  profound  anaemia;  i.e.,  when  the  haemo- 
globin is  twenty-five  per  cent  or  less.  It  can  sometimes  be  abolished 
by  pressing  the  jugular  bulb  and  can  then  be  observed,  if  followed 
to  the  neck,  to  pass  over  gradually  into  a  continuous  venous  hum  with 
a  diastolic  accent. 

.    J  Cabot  and  Locke,  Johns  Hopkins  Bulletin,  May,  1903. 


X 

AUSCULTATION  OF  THE  HEART.  197 

Cardio- Respiratory  Murmurs. 

When  a  portion  of  the  free  margin  of  the  lung  is  fixed  by  ad- 
hesions in  a  position  overlapping  the  heart,  the  cardiac  movements 
may  rhythmically  displace  the  air  in  such  piece  of  lung  so  as  to 
give  rise  to  sounds  which  at  times  closely  simulate  cardiac  mur- 
murs. These  conditions  are  most  often  to  be  found  in  the  tongue- 
like  projection  of  the  left  lung,  which  normally  overlaps  the  heart, 
but  it  is  probably  the  case  that  cardio-respiratory  murmurs  may  be 
produced  without  any  adhesion  of  the  lung  to  the  pericardium 
under  conditions  not  at  present  understood.  Such  murmurs  may 
be  heard  under  the  left  clavicle  or  below  the  angle  of  the  left  scap- 
ula, as  well  as  near  the  apex  of  the  heart, — less  often  in  other  parts 
of  the  chest. 

Cardio-respiratory  murmurs  may  be  either  systolic  or  diastolic, 
but  the  vast  majority  of  cases  are  systolic.  The  area  over  which 
they  are  audible  is  usually  a  very  limited  one.  They  are  greatly 
affected  by  position  and  by  respiration,  and  are  heard  most  distinctly 
if  not  exclusively  during  inspiration,  especially  at  the  end  of  that 
act.  (This  fact  is  an  important  aid  in  distinguishing  them  from 
true  cardiac  murmurs,  which  are  almost  always  fainter  at  the  end 
of  inspiration.)  They  are  also  greatly  affected  by  cough  or  forced 
respiration  or  by  holding  the  breath,  whereas  cardiac  murmurs 
are  relatively  little  changed  thereby.  Pressure  on  the  outside 
of  the  thorax  and  in  their  vicinity  may  greatly  modify  their  in- 
tensity or  quality,  while  organic  cardiac  murmurs  are  but  little 
influenced  by  pressure.  As  a  rule,  they  have  the  quality  of  nor- 
mal respiratory  murmur,  and  sound  like  an  inspiration  interrupted 
by  each  diastole  of  the  heart. 

In  case  the  effect  of  the  cardiac  movements  is  exerted  upon  a 
piece  of  lung  in  which  a  catarrhal  process  is  going  on,  we  may  have 
systolic  or  diastolic  explosions  of  rales,  or  any  type  of  respiratory 
murmur  except  the  bronchial  type,  since  this  is  produced  in  solid  lung 
which  could  not  be  emptied  or  filled  under  the  influence  of  the  car- 
diac movements.  Cardio-respiratory  murmurs  have  no  special  diag- 
nostic significance,  and  are  mentioned  here  only  on  account  of  the  im- 


198  PHYSICAL  DIAGNOSIS. 

portance  of  not  confusing  them  with  true  cardiac  murmurs.     They 
were  formerly  thought  to  indicate  phthisis,  but  such  is  not  the  case. 

Murmurs  of  Venous  Origin. 

I  have  already  mentioned  that  the  venous  hum  so  often  heard 
in  the  neck  in  cases  of  anaemia  may  be  transmitted  to  the  region  of 
the  base  of  the  heart  and  heard  there  as  a  diastolic  murmur  owing 
to  the  acceleration  of  the  venous  current  by  the  aspiration  of  the 
right  ventricle  during  diastole.  Such  murmurs  are  very  rare  and 
may  usually  be  obliterated  by  pressure  upon  the  bulbus  jugularis, 
or  even  by  the  compression  brought  to  bear  upon  the  veins  of  the 
neck  when  the  head  is  sharply  turned  to  one  side.  They  are  heard 
better  in  the  upright  position  and  during  inspiration. 

Arterial  Murmurs. 

(1)  Eoughening  of  the  arch  of  the  aorta,  due  to  chronic  end- 
aortitis,  is  a  frequent  cause  in  elderly  men  of  a  systolic  murmur, 
heard  best  at  the  base  of  the  heart  and  transmitted  into  the  vessels 
of  the  neck.     Such  a  murmur  is  very  rarely  accompanied  by  a  pal- 
pable thrill.     From  cardiac  murmurs  it  is  distinguished  by  the  lack 
of  any  other  evidence  of  cardiac  disease  and  the  presence  of  marked 
arterio-sclerosis  in  the  peripheral  vessels  (see  further   discussion 
under  Aortic  Stenosis,  p.  239,  and  under  Aneurism,  p.  282). 

(2)  A  narrowing  of  the  lumen  of  the  subclavian  artery,  due  to 
some  abnormality  in   its  course,  may  give  rise  to  a  systolic  mur- 
mur heard  close  below  the  clavicle  at  its  outer  end.     The  mur- 
mur is  greatly  influenced  by  movements  of  the  arm  and  especially 
by  respiratory  movements.     During  inspiration  it  is  much  louder, 
and  at  the  end  of  a  forced  expiration  it  may  disappear  altogether. 
Occasionally  such  murmurs  are  transmitted  through  the  clavicle  so 
as  to  be  audible  above  it. 

(3)  Pressure  exerted  upon  any  of  the  superficial  arteries  (carot- 
id, femoral,  etc.)  produces  a  systolic  murmur  (see  below,  p.  237). 
Diastolic  arterial  murmurs  are  peculiar  to  aortic  regurgitation. 

(4)  Over  the  anterior  fontanelle  in  infants  and  over  the  gravid 
uterus  systolic  murmurs  are  to  be  heard  which  are  probably  arterial 
in  origin. 


CHAPTER   X. 
DISEASES  OF  THE   HEART. 

VALVULAR   LESIONS. 

CLINICALLY  it  is  convenient  to  divide  the  ills  which  befall  the 
heart  into  three  classes : 

(1)  Those  which  deform  the  cardiac  valves  (valvular  lesions). 

(2)  Those  which  weaken  the  heart  wall  (parietal  disease). 

(3)  Congenital  malformations. 

Lesions  which  affect  the  cardiac  valves  without  deforming  them 
are  not  often  recognizable  during  life.  The  vegetations  of  acute 
endocarditis1  do  not  usually  produce  any  peculiar  physical  signs 
until  they  have  so  far  deformed  or  obstructed  the  valves  as  to  pre- 
vent their  opening  or  closing  properly. 

The  murmurs  which  are  often  heard  over  the  heart  in  cases  of 
acute  articular  rheumatism  cannot  be  considered  as  evidence  of 
vegetative  endocarditis  unless  valvular  deformities,  and  their  re- 
stilts  in  valvular  obstruction  or  incouipetency,  ensue.  The  chordae 
tendineae  may  be  ruptured  or  shortened,  thickened,  and  welded  to- 
gether into  shapeless  masses,  but  if  these  deformities  do  not  affect 
the  action  of  the  valves  we  have  no  means  of  recognizing  them  dur- 
ing life.  Congenital  malformations  are  practically  unrecognizable 
as  such.  If  they  do  not  affect  the  valves,  we  cannot  with  any  cer- 
tainty make  out  what  is  wrong. 

For  physical  diagnosis,  then,  heart  disease  means  either  de- 
1  See  Appendix. 


200 


PHYSICAL  DIAGNOSIS. 


formed  valves  or  weakened  walls.  Whatever  else  may  exist,  we 
are  none  the  wiser  for  it  unless  the  autopsy  enlightens  us. 

In  this  chapter  I  shall  confine  myself  to  the  discussion  of  valvu- 
lar lesions  and  their  results. 

Valvular  lesions  are  of  two  types : 

(a)  Those  which  produje  partial  obstruction  of  a  valve  orifice 
or  prevent  its  opening  fully  ( "  stenosis  ") . 


FIG.  117.— The  Base  of  the  Contracted  Heart  Showing  Spv>'ncteric  Action  of  the  Muscular  Fibres 
Surrounding  the  Mitral  and  Tricuspld  Valves.  The  outer  dotted  line  is  the  outline  of  the 
relaxed  heart.  The  Inner  dotted  circles  show  the  size  of  the  mitral  and  tricuspid  valves 
during  diastole,  a.  Outline  of  the  heart  when  relaxed ;  b,  outline  of  the  relaxed  tricuspid 
valve ;  c,  outline  of  the  mitral  orifice  during  diastole.  (Af  er  Spalteholz.) 

(b)  Those  which  produce  leakage  through  a  valve  orifice  or 
prevent  its  closing  effectively  ( " regurgitation, "  "insufficiency," 
"  incompetency  ") . 


VALVULAR  LESIONS. 


201 


Stenosis  results  always  from  the  stiffening,  thickening,  and  con- 
traction of  a  valve. 

Regurgitation,  on  the  other  hand,  may  be  the  result  either  of — 

(a)  Deformity  of  a  valve,  or 

(&)  Weakening  of  the  heart  muscle. 

The  mitral  and  tricuspid  orifices  are  closed  not  simply  by  the 
shutting  of  their  valves,  but.  also  in  part  by  the  sphincter-like 

Mitral  curtains. 


Myocardium. 


Pericardium. 


FIG.  118.— The  Mitral  Valve  Closed,  Showing  the  Action  of  the  Papillary  Muscles.    (After 

Spalteholz.) 

action  of  the  circular  fibres  of  the  heart  wall  (see  Fig.  117)  ami  u.e 
contraction  of  the  papillary  muscles  (Fig.  118). 

In  birds  the  tricuspid  orifice  has  no  valve  and  is  closed  wholly 
by  the  muscular  sphincter  of  the  heart  wall. 

In  conditions  of  very  acute  cardiac  failure,  such  as  may  occur 
after  a  hard  run,  the  papillary  muscles  are  in  all  probability  relaxed, 
so  that  the  valve-flaps  swing  back  into  the  auricle  and  permit  regur- 
gitation  of  blood  from  the  vertricle. 


202  PHYSICAL  DIAGNOSIS. 

Valvular  incompetence,  then,  differs  from  valvular  obstruction 
in  that  the  latter  always  involves  deformity  and  stiffening  of  valves, 
while  incompetence  or  leakage  is  often  the  result  of  deficient  mus- 
cular action  on  the  part  of  the  heart  wall.  An  osbtructed  valve  is 
almost  always  leaky  as  well,  since  the  same  deformities  which  pre- 
vent a  valve  from  opening  usually  prevent  its  closure ;  but  this  rule 
does  not  work  backward.  A  leaky  valve  is  often  not  obstructed. 
It  is  leaky  but  not  osbtructed  if  the  valve  curtain  has  been  practi- 
cally destroyed  by  endocarditis;  or,  again,  it  is  leaky  but  not  ob- 
structed if  the  leak  represents  muscular  weakening  of  the  mitral 
sphincter  or  of  the  papillary  muscles.  Pure  stenosis  is  very  rare. 
Pure  regurgitation  is  very  common,  especially  at  the  mitral. 

When  valves  are  so  deformed  that  their  orifice  is  both  leaky  and 
obstructed,  we  have  what  is  known  as  a  "  combined  "  or  "  double  " 
valve  lesion. 

Since  valvular  lesions  are  recognized  largely  by  their  results, 
first  upon  the  walls  of  the  heart  itself  and  then  upon  the  other 
organs  of  the  body,  it  seems  best  to  give  some  account  of  these 
results  before  passing  on  to  the  description  of  the  individual  le- 
sions in  the  heart  itself. 

The  results  of  valvular  lesions  are  first  conservative  and  latex 
destructive.  The  conservative  results  are  known  as : 

The  establishment  of  compensation  through  hypertrophy. 

The  destructive  or  degenerative  results  are  known  as : 

The  failure  of  compensation  through  (or  without)  dilatation 

I  shall  consider,  then, 

(a)  The  establishment  and  the  failure  of  compensation. 

(b)  Cardiac  hypertrophy. 

(c)  Cardiac  dilatation. 

ESTABLISHMENT     AND     FAILURE     OF     COMPENSATION     IN 
VALVULAR  DISEASE  OF  THE   HEART. 

We  may  discriminate  three  periods  in  the  progress  of  a  case  oi 
valvular  heart  disease : 


VALVULAR  LESIONS.  203 

(1)  The  period  before  the  establishment  of  compensation. 

(2)  The  period  of  compensation. 

(3)  The  period  of  failing  or  ruptured  compensation. 

(1)    Compensation  Not  Yet  Established. 

In  most  cases  of  acute  valvular  endocarditis,  wKether  of  the 
relatively  benign  or  of  the  malignant  type,  there  is  a  time  when 
the  lesion  is  perfectly  recognizable  despite  the  fact  that  compensa- 
tory hypertrophy  has  not  yet  occurred.  In  some  cases  this  period 
may  last  for  months ;  the  heart  is  not  enlarged,  there  is  no  accentu- 
ation of  either  second  sound  at  the  base,  there  is  no  venous  stasis, 
and  our  diagnosis  must  rest  solely  upon  the  presence  and  character- 
istics of  the  murmur.  For  example,  in  early  cases  of  mitral  regur- 
gitation  due  to  chorea  or  rheumatism,  the  disease  may  be  recog- 
nized by  the  presence  of  a  loud  musical  murmur  heard  in  the  back 
as  well  as  at  the  apex  and  in  the  axilla.  In  the  earlier  stages  of 
aortic  regurgitation  occurring  in  young  people  as  a  complication  of 
rheumatic  fever,  there  may  be  absolutely  no  evidence  of  the  valve 
lesion  except  the  characteristic  diastolic  murmur.  In  most  text- 
books of  physical  diagnosis  I  think  too  little  attention  is  given  to 
this  stage  of  the  disease. 

(2)  The  Period  of  Compensation. 

Valvular  disease  would,  however,  soon  prove  fatal  were  it  not 
for  the  occurrence  of  compensatory  hypertrophy  of  the  heart  walls. 
To  a  certain  extent  the  heart  contracts  as  a  single  muscle,  and  in- 
creases the  size  of  all  its  walls  in  response  to  the  demand  for  in- 
creased work ;  but  as  a  rule  the  hypertrophy  affects  especially  one 
ventricle — that  ventricle,  namely,  upon  which  especially  demand  is 
made  for  increased  power  in  order  to  overcome  an  increased  resist- 
ance in  the  vascular  circuit  which  it  supplies  with  blood.  What- 
ever increases  the  resistance  in  the  lungs  brings  increased  work 
upon  the  right  ventricle ;  whatever  increases  the  resistance  in  the 
aorta  or  peripheral  arteries  increases  the  amount  of  work  which  the 
left  ventricle  must  do. 


204  PHYSICAL  DIAGNOSIS. 

Now,  any  disease  of  the  mitral  valve,  whether  obstruction  or 
leakage,  results  in  engorgement  of  the  lungs  with  blood,  and  hence 
demands  an  increased  amount  of  work  011  the  part  of  the  right 
ventricle  in  order  to  force  the  blood  through  the  overcrowded  pul- 
monary vessels ;  hence  it  is  in  mitral  disease  that  we  find  the  great- 
est compensatory  hypertrophy  of  the  right  ventricle. 

On  the  other  hand,  it  is  obvious  that  obstruction  at  the  aortic 
valves  or  in  the  peripheral  arteries  (arterio-sclerosis)  demands  an 
increase  in  power  in  the  left  ventricle,  in  order  that  the  requisite 
amount  of  blood  may  be  forced  through  arteries  of  reduced  calibre, 
while  if  the  aortic  valve  is  so  diseased  that  a  part  of  the  blood 
thrown  into  the  aorta  by  the  left  ventricle  returns  into  that  ven- 
tricle, its  work  is  thereby  greatly  increased,  since  it  has  to  contract 
upon  a  larger  volume  of  blood. 

In  response  to  these  demands  for  increased  work,  the  musculai 
wall  of  the  left  ventricle  increases  in  thickness,  and  compensation  is 
thus  established  at  the  cost  of  an  increased  amount  of  work  on  the 
part  of  the  heart. ' 

(3)  failure  of  Compensation. 

Sooner  or  later  in  the  vast  majority  of  cases  the  heart,  handi- 
capped as  it  is  by  a  leakage  or  obstruction  of  one  or  more  valves, 
becomes  unable  to  meet  the  demands  made  upon  it  by  the  needs  of 
the  circulation.  Failure  of  compensation  is  sometimes  associated 
with  dilatation  of  the  heart  and  weakening  of  its  walls.  Not  in- 
frequently recurrent  attacks  of  "failing  compensation  "  represent  a 
flare-up  of  a  smoulder  ing  endocarditis  as  the  accompanying  leiicocy- 
tosis  (with  or  without  fever)  suggests.  This  is  especially  common  in 
children  but  occurs  also  in  young  adults.  Sometimes,  however, 
neither  mechanical  nor  infectious  changes  can  be  found.  Whatever 
the  cause  may  be,  the  result  of  ruptured  compensation  is  venous 
stasis;  that  is,  oedema  or  dropsy  of  various  organs  appears.  If  the 
left  ventricle  is  especially  weakened,  dropsy  appears  first  in  the 
legs,  on  account  of  the  influence  of  gravity,  soon  after  in  the  geni- 

1  Rosenbach  brings  forward  evidence  to  show  that  the  arteries,  the  lungs, 
and  other  organs  actively  assist  in  maintaining  compensation. 


VALVULAR  LESIONS.  205 

tals,  lungs,  liver,  and  the  serous  cavities.  Engorgement  of  the 
lungs  is  especially  marked  in  cases  of  mitral  disease  with,  weakening 
of  the  right  ventricle,  and  is  manifested  by  dyspnoea,  cyarosis, 
cough,  and  haemoptysis.  In  many  cases,  however,  dropsy  is  very 
irregularly  and  unaccountably  distributed,  and  does  not  follow  the 
rules  just  given.  In  pure  aortic  disease,  uncomplicated  by  leakage 
of  the  mitral  vulve,  dropsy  is  a  relatively  late  symptom,  and  pre- 
cordial  pain  (angina  pectoris)  is  more  prominent. 

HYPERTROPHY   AND   DILATATION. 

Since  cardiac  hypertrophy  or  dilatation  are  not  in  themselves 
diseases,  but  may  occur  in  any  disease  of  the  heart  (valvular  or 
parietal),  it  seems  best  to  give  some  account  of  them  and  of  the 
methods  by  which  they  may  be  recognized,  before  taking  up  sepa- 
rately the  different  lesions  with  which  they  are  associated. 


1.    Cardiac  Hypertrophy. 

Hypertrophy  of  the  heart  is  usually  due  to  the  following  causes : 

First  (and  most  frequent) :  Valvular  disease  of  the  heart  itself. 
Second:  Obstruction  of  the  flow  of  blood  through  the  arteries 
owing  to  increase  of  arterial  resistance,  such  as  occurs  in  chronic 
nephritis  and  arterio-sclerosis.  Third :  Obstruction  to  the  circula- 
tion of  the  blood  through  the  lungs  (emphysema,  cirrhosis  of  the 
lung,  fibroid  phthisis).  Fourth:  Severe  and  prolonged  muscular 
exertion  (athlete's  heart).  Fifth:  Adherent  Pericardium. 

In  valvular  disease  the  greatest  degree  of  hypertrophy  is  to  be 
seen  usually  in  relatively  young  persons,  and  especially  when  the 
advance  of  the  lesion  is  not  very  rapid. 

Hypertrophy  of  the  heart  in  valvular  disease  is  also  influenced 
by  the  amount  of  muscular  work  done  by  the  patient,  by  the  de- 
gree of  vascular  tension,  and  by  the  treatment.  In  the  great  major- 
ity of  cases  of  hypertrophy,  from  whatever  cause,  both  sides  of  the 
heart  are  affected,  but  we  may.  distinguish  cases  in  which  one  or  the 
other  ventricle  is  predominantly  affected. 


206  PHYSICAL  DIAGNOSIS. 

(1)    Cardiac  hypertrophy  affecting  especially  the  left  ventricle. 

(a)  The  apex  impulse  is  usually  lower  than  normal,  often  in 
the  sixth  space,  occasionally  in  the  seventh  or  eighth.1     It  is  also 
farther  to  the  left  than  normal,  but  far  less  so  than  in  cases  in 
which  the  hypertrophy  affects  especially  the  right  ventricle.     The 
area  of  visible  pulsation  is  usually  increased,  and  a  considerable  por- 
tion of  the  chest  wall  may  be  seen  to  move  with  each  systole  of  the 
heart,  while  frequently  there  is  a  systolic  retraction  of  the  inter- 
spaces in  place  of  a  systolic  impulse. 

(b)  Palpation  confirms  the  results  of  inspection  and  shows  us 
also  that  the  apex  impulse    is    unusually  powerful.  -  Percussion 
shows  in  many  cases  that  the  cardiac  dulness  is  more  intense  and 
its  area  increased  downward  and  to  a  lesser  extent  toward  the  left.2 

(c)  If  we  listen  in  the  region  of  the  maximum  cardiac  impulse, 
we  generally  hear  an  unusually  long  and  low-pitched  first  sound, 
which  may  or  may  not  be  of  a  greater  intensity  than  normal.     A 
very  loud  first  sound  is  much  more  characteristic  of  a  cardiac  weak- 
ness or  neurosis  than  of  pure  hypertrophy  of  the  left  ventricle. 

The  second  sound  at  the  apex  (the  aortic  second  sound  trans- 
mitted) is  usually  much  louder  and  sharper  than  usual.  Ausculta- 
tion in  the  aortic  area  shows  that  the  second  sound  at  that  point  is 
loud  and  ringing  in  character.  Not  infrequently  the  peripheral  ar- 
teries (the  subclavians,  brachials,  carotids,  radials,  and  femorals) 
may  be  seen  to  pulsate  with  each  systole  of  the  heart.  This  sign  is 
most  frequently  observed  in  cases  of  hypertrophy  of  the  left  ven- 
tricle, which  are  due  to  aortic  regurgitation,  but  is  by  no  means 
peculiar  to  this  disease  and  may  be  repeatedly  observed  when  the 
cardiac  hypertrophy  is  due  to  nephritis  or  muscular  work.  I  have 
frequently  observed  it  in  healthy  athletes,  (d)  Peripheral  blood 
pressure  is  increased  (see  above,  p.  111). 

The  radial  pulse  wave  has  no  constant  characteristics,  b"t  de- 

1  This  is  due  partly  to  a  stretching  of  the  aorta,  produced  by  the  increased 
weight  of  the  heart. 

2  Post  mortem  enlarged  left  ventricle  is  often  found  despite  the  absence  of 
the  above  signs  in  .life  because  it  extends  backward  out  of  our  reach. 


VALVULAR  LESIONS.  207 

pends  rather  upon  the  cause  which  has  produced  the  hypertrophy 
than  upon  the  hypertrophy  itself. 

(2)   Cardiac  Hypertrophy  Affecting  Especially  the  Right   Ventricle. 

It  is  much  more  difficult  to  be  certain  of  the  existence  of  en- 
largement of  the  right  ventricle  than  of  the  left.  Practically  we 
have  but  two  reliable  physical  signs : 

(a)  Increase  in  the  transverse  diameter  of  the  heart,  as  shown 
by  the  position  of  the  apex  impulse  and  by  percussion  of  the  right 
and  left  borders  of  the  heart ;  and 

(&)  Accentuation  of  the  pulrnonic  second  sound,  which  is  often 
palpable  as  well  as  audible. 

The  apex  beat  is  displaced  both  to  the  left  and  downward,  but 
especially  to  the  left.  In  cases  of  long-standing  mitral  disease,  the 
cardiac  impulse  may  be  felt  in  mid-axilla,  several  inches  outside  the 
nipple,  and  yet  not  lower  down  than  the  sixth  intercostal  space. 
In  a  small  percentage  of  cases  (i.e.,  when  the  right  auricle  is  en- 
gorged), an  increased  area  of  dulness  to  the  right  of  the  sternum 
may  be  demonstrated.  Accentuation  of  the  pulmonic  second  sound 
is  almost  invariably  present  in  hypertrophy  of  the  right  ventricle, 
though  it  is  not  peculiar  to  that  condition.  It  may  be  heard,  for 
example,  in  cases  of  pneumonia  when  no  such  hypertrophy  is  pres- 
ent, but  in  the  vast  majority  of  cases  of  cardiac  disease  we  may 
infer  the  presence  and  to  some  extent  the  amount  of  hypertrophy 
of  the  right  ventricle  from  the  presence  of  a  greater  or  lesser  ac- 
centuation of  the  pulmonic  second  sound.  The  radial  pulse  shows 
nothing  characteristic  of  this  type  of  hypertrophy. 

Epigastric  pulsation  gives  us  no  evidence  of  the  existence  of 
hypertrophy  of  the  right  ventricle,  despite  contrary  statements  in 
many  text-books.  Such  pulsation  is  frequently  to  be  seen  in  per- 
sons with  normal  hearts,  and  is  frequently  absent  when  the  right 
ventricle  is  obviously  hypertrophied.  It  is  perhaps  most  often  due 
to  an  unusually  low  position  of  the  whole  heart. 


208 


PHYSICAL  DIAGNOSIS. 


DILATATION  OF  THE  HEART. 

(1)  Acute  Dilatation. — Immediately  after  severe  museular  exer- 
tion, as,  for  example,  at  the  finish  of  a  boat  race,  or  of  a  two-mile 
run  (especially  in  persons  not  properly  trained),  an  acute  cardiac 
dilatation  is  said  to  occur,  and  in  debilitated  or  poorly  nourished 
subjects  such  an  acute  dilatation  may  be  serious  or  even  fatal  in  its 
results.     I  have  never  seen  this  in  healthy  persons. 

(2)  Chronic  dilatation  comes  on  gradually  as  a  result  of  valvu- 


FIG.  119. —Dilated  Heart.    From  v.  Ziemssen's  Atlas. 

lar  disease  or  other  cause,  and  gives  rise  to  practically  the  same 
physical  signs  as  those  of  acute  dilatation,  from  which  it  differs 
chiefly  as  regards  the  accompanying  physical  phenomena  and  the 
prognosis,  Briefly  stated,  the  signs  of  dilatation  of  the  heart, 
whether  acute  or  chronic,  are : 

(a)  Feebleness  and  irregularity  of  the  apex  impulse  and  of  the 
radial  impulse,  (£>)  enlargement  of  the  heart,  as  indicated  by  inspec- 
tion, palpation,  and  percussion,  and  (sometimes)  (c)  murmurs  indi- 
cative of  stretching  of  one  of  another  of  the  valvular  orifices. 


VALVULAR  LESIONS.  209 


Dilatation  of  the  Left   Ventricle. 

Inspection  shows  little  that  is  not  better  brought  out  by  palpa- 
tion. Palpation  reveals  a  "flapping"  cardiac  impulse,  or  a  vague 
shock  displaced  both  downward  and  to  the  left  and  diffused  over 
an  abnormally  large  area  of  the  chest  wall.  Percussion  verifies 
the  position  of  the  cardiac  impulse  and  sometimes  shows  an  unusu- 
ally blunt  or  rounded  outline  at  the  apex  of  the  heart. 

On  auscultation,  the  first  sound  is  usually  very  short  and  sharp, 
but  not  feeble  unless  it  is  accompanied  by  a  murmur.  In  case  the 
mitral  orifice  is  so  stretched  as  to  render  the  valve  incompetent,  or 
in  case  the  muscles  of  the  heart  are  so  fatigued  and  weakened  that 
they  do  not  assist  in  closing  the  mitral  orifice,  a  systolic  murmur  is 
to  be  heard  at  the  apex  of  the  heart.  This  murmur  is  transmitted 
to  the  axilla  and  back,  but  does  not  usually  replace  the  first  sound 
of  the  heart.  The  aortic  second  sound,  as  heard  in  the  aortic  area 
and  at  the  apex,  is  feeble. 

Dilatation  of  the  right  ventricle  of  the  heart  is  manifested  by  an 
increase  in  the  area  of  cardiac  dulness  to  the  right  of  the  sternum 
(corresponding  to  the  position  of  the  right  auricle),  by  feebleness  of 
the  pulmonic  second  sound  together  with  signs  of  congestion  and 
engorgement  of  the  lungs,  and  often  by  a  systolic  murmur  at  the 
tricuspid  valve;  i.e  ,  at  or  near  the  root  of  the  ensiform  cartilage. 
When  this  latter  event  occurs,  one  may  have  also  systolic  pulsation 
in  the  jugular  veins  and  in  the  liver  (see  below,  p.  248). 

In  cases  of  acute  dilatation,  such  as  occur  in  infectious  fevers  or 
in  chronic  latent  myocardial  disease,  there  is  often  to  be  heard  a 
systolic  murmur  loudest  in  the  pulmonary  area  and  due  very  possi- 
bly to  a  dilatation  of  the  conus  arteriosus. 

The  diagnosis  of  dilatation  of  the  heart  seldom  rests  entirely 
upon  physical  signs  referable  to  the  heart  itself.  In  acute  cases 
our  diagnosis  is  materially  aided  by  a  knowledge  of  the  cause, 
which  is  often  tolerably  obvious.  In  chronic  cases  the  best  evi- 
dence of  dilatation  is  often  that  furnished  by  the  venous  stasis 
which  results  from  it. 

14 


210  PHYSICAL  DIAGNOSIS. 

(4)  CHRONIC  VALVULAR  DISEASE. 
I.   MITRAL  REGURGITATION. 

The  commonest  and  probably  one  of  the  least  serious  of  valvular 
lesions  is  incompetency  of  the  mitral.  It  results  in  most  cases 
from  the  shortening,  stiffening,  and  thickening  of  the  valve  pro- 
duced by  rheumatic  endocarditis  in  early  life.  It  is  the  lesion  pres- 
ent in  most  cases  of  chorea  (see  Figs.  120  and  121). 

Temporary  and  curable  mitral  regurgitation  may  result  from 
weakening  of  the  heart  muscle,  which  normally  assists  in  closing 
the  mitral  orifice  through  the  sphincter-like  contraction  of  its  cir- 
cular fibres. 

Great  muscular  fatigue,  such  as  is  produced  by  a  .hard  boat 
race,  may  result  in  a  temporary  relaxation  of  the  mitral  sphincter 
or  of  the  papillary  muscles  sufficient  to  allow  of  genuine  but  tem- 
porary and  curable  regurgitation  through  the  mitral  orifice.  In 
conditions  of  profound  nervous  debility,  excitement,  or  exhaustion, 
similar  weakening  of  the  cardiac  muscles  may  allow  of  a  leakage 
through  the  mitral,  which  ceases  with  the  removal  of  its  cause. 
Stress  has  been  laid  upon  these  points  by  Prhice,  and  recently  by 
Arnold.  ^ 

Mitral  insufficiency  due  to  stretching  of  the  ring  into  which  the 
valve  is  inserted  occurs  not  unfrequently  as  a  result  of  dilatation 
of  the  left  ventricle,  and  is  commonly  known  as  relative  insufficiency 
of  the  mitral  valve.  The  valve  orifice  can  enlarge,  the  valve  can- 
not, and  hence  its  curtains  are  insufficient  to  fill  up  the  dilated  ori- 
fice. This  type  of  mitral  insufficiency  frequently  results  from 
aortic  regurgitation  with  the  dilatation  of  the  left  ventricle  which 
that  lesion  produces,  or  from  myocarditis,  which  weakens  the  heart 
wall  until  it  dilates  and  widens  the  mitral  orifice. 

The  results  of  any  form  of  mitral  leakage  occur  in  this  order : 

1.  Dilatation  or  hypertrophy  of  the  left  auricle,  which  has  to 
receive  blood  both  from  the  lungs  and  through  the  leaky  mitral 
from  the  left  ventricle. 

2.  The  overfilled  left  auricle  cannot  receive  the  blood  from  the 


VALVULAR  LESIONS. 


211 


lungs  as  readily  as  it  should;  hence  the  blood  "backs  up"  in  the 
lungs  and  thereby  increases  the  work  which  the  right  ventricle 
must  do  in  order  to  force  the  blood  through  them.  Thus  result 
oedema  of  the  lungs,  and — 


FIG.  121. 
FIG.  120.— Normal  Heart  during  Systole.    Mitral  valve  closed ;  blood  flowing  through  the  open 

aortic  valves  into  the  aorta. 
FIG.  121.— Mitral  Regurgitation.    The  In-art  is  in  systole  and  the  arrows  show  the  current  flowing 

back  in  the  left  auricle  as  well  as  forward  into  the  aorta. 


212  PHYSICAL  DIAGNOSIS. 

(3)  Hypertrophy  and  dilatation  of  the  right  ventricle,  which  in 
turn  becomes  sooner  or  later  overcrowded  so  that  the  trieuspid 
valve  gives  way  and  trieuspid  leakage  occurs. 

(4)  The  capacity  for  hypertrophy  possessed  by  the  right  auricle 
is  soon  exhausted,  and  we  get  then — 

(5)  General  venous  stasis,  which  shows  itself  first  as  venous 
pulsation  in  the  jugulars  and  in  the  liver  and  later  in  the  tissues 
drained  by  the  portal  and  peripheral  veins.     This  venous  stasis  in- 
creases the  work  of  the  left  ventricle,  and  so  we  get — 

(6)  Hypertrophy  and  dilatation  of  the  left  ventricle.     Hyper- 
trophy of  the  left  ventricle  is  also  produced  by  the  increased  work 
necessary  to  maintain  some  vestige  of  sphincter  action  at  the  leaky 
mitral  orifice,  as  well  as  by  the  labor  of  contracting  upon  the  extra 
quantity  of  blood  delivered  to  it  by  the  enlarged  left  auricle. 

At  last  the  circle  is  complete.  Every  chamber  in  the  heart  is 
enlarged,  overworked,  and  failure  is  imminent. 

Returning  now  to  the  signs  of  mitral  re  gurgitation,  we  shall  find 
it  most  convenient  to  consider  first  the  type  of  regurgitation  pro- 
duced by  rheumatism  and  resulting  in  thickening,  stiffening,  and 
retraction  of  the  valve. 

PHYSICAL  SIGNS. 

(a)  First  Stage — Prior  to  the  Establishment  of  Compensation. 

We  have  but  one  characteristic  physical  sign : 

A  systolic  murmur  heard  loudest  at  the  apex  of  the  heart,  trans- 
mitted to  the  back  (below  or  inside  the  left  scapula)  and  to  the  left 
axilla.  The  murmur  is  not  infrequently  musical  in  character,  and 
when  this  is  the  case  diagnosis  is  much  easier.  Systolic  musical 
murmurs  so  transmitted  do  not  occur  without  valvular  leakage. 
Rosenbach  believes  that  adherent  pericardium  is  capable  of  produc- 
ing such  a  murmur,  but  only,  if  I  understand  him  rightly,  in  case 
there  is  a  genuine  mitral  leakage  due  to  the  embarrassing  embrace 
of  the  pericardium  which  prevents  the  mitral  orifice  from  closing. 

"Functional"  or  "haemic"  murmurs  are  rarely  heard  in  the 
back,  and  very  rarely,  if  ever,  have  a  musical  quality. 


VALVULAR  LESIONS.  213 

Cases  of  mitral  regurgitation  are  not  very  often  seen  at  this 
stage,  but  in  acute  endocarditis  after  the  fever  and  anaemia  have 
subsided,  or  in  chorea,  such  a  murmur  may  exist  for  days  or  weeks 
before  any  accentuation  of  the  pulmonic  second  sound  or  any  en- 
largement of  the  heart  appears.  I  have  had  the  opportunity  of 
verifying  the  diagnosis  at  autopsy  in  two  such  cases. 

(b)  Second  Stage —  Compensation  Established. 

As  long  as  compensation  remains  perfect,  the  only  evidence  of 
regurgitation  may  be  that  obtained  by  auscultation,  and  I  shall 
accordingly  begin  with  this  rather  than  in  the  traditional  way  with 
inspection,  palpation,  and  percussion. 

The  distinguishing  auscultatory  phenomena  in  cases  of  well- 
compensated  mitral  insufficiency  are : 

(a)  A  systolic  murmur  whose  maximum  intensity  is  at  or  near 
the  apex  impulse  of  the  heart,  but  which  is  also  to  be  heard  in  the 
left  axilla  and  in  the  back  below  or  inside  the  angle  of  the  left 
scapula  (so  far  the  signs  are  those  of  the  first  stage,  above  de- 
scribed). 

(£>)  A  pathological  accentuation  of  the  pulmonic  second  sound. 

This  is  the  minimum  of  evidence  upon  which  it  is  justifiable  to 
make  the  diagnosis  of  compensated  mitral  regurgitation.  In  the 
vast  majority  of  cases,  however,  our  diagnosis  is  confirmed  by  the 
following  additional  data: 

(c)  Enlargement  of  the  heart  as  shown  by  inspection,  palpation, 
and  percussion. 

The  pulse  hi  well-compensated  cases  shows  no  considerable 
abnormality.  When  compensation  begins  to  fail,  or  sometimes  be- 
fore that  time,  the  most  characteristic  thing  about  the  pulse  is  its 
marked  irregularity  both  hi  force  and  rhythm.  Such  irregularity 
is  at  once  more  common  and  less  serious  in  mitral  disease  than  in 
that  of  any  other  valve  ;  it  may  continue  for  years  and  be  compat- 
ible with  very  tolerable  health. 


214  PHYSICAL  DIAGNOSIS. 

Returning  now  to  the  details  of  the  sketch  just  given,  we  will 
take  up  first  — 

(a)  The  Murmur. — In  children  the  murmur  of  mitral  regurgita- 
tion  may  be  among  the  loudest  of  all  murmurs  to  be  heard  in  val- 

1st 

2nd. 


12nd 
llllllln.l I 


FIG.  122.— Diagram  to  Represent  Systolic  Mitral  Murmur.  The  heavy  lines  represent  th«  normal 
cardiac  sounds  and  the  light  lines  the  murmur,  which  In  this  case  does  not  replace  the  first 
sound  and  '•  tapers  "  oft  characteristically  at  the  end. 

vular  disease,  but  this  does  not  necessarily  imply  that  the  lesion  is 
a  very  severe  one.  A  murmur  which  grows  louder  under  observa- 
tion in  a  well-compensated  valvular  lesion  may  mean  an  advance  of 
the  disease,  but  if  the  case  is  first  seen  after  compensation  has 
failed  a  faint,  variable  whiff  in  the  mitral  area  may  mean  the  se- 
verest type  of  lesion.  As  the  patient  improves  under  the  influence 
of  rest  and  cardiac  tonics,  such  a  murmur  may  grow  very  much 
louder,  or  a  murmur  previously  inaudible  may  appear. 

The  length  of  the  murmur  varies  a  great  deal  in  different  cases 
and  is  not  of  any  great  practical  importance.  It  rarely  ends 
abruptly,  but  usually  "tails  off"  at  the  end  of  systole  (see  Fig.  122). 
Musical  murmurs  are  heard  more  often  in  mitral  regurgitation  than 
in  any  other  valve  lesion,  but  the  musical  quality  rarely  lasts 
throughout  the  whole  duration  of  the  murmur,  contrasting  in  this 
respect  with  musical  murmurs  produced  at  the  aortic  valve.  The 


FIG.  123.— Systolic  Mitral  Murmur  Replacing  the  First  Sound  of  the  Heart. 

first  sound  of  the  heart  may  or  may  not  be  replaced  by  the  murmur 
(see  Fig.  123).  When  the  sound  persists  and  is  heard  either  with 
or  before  the  murmur,  one  can  infer  that  the  lesion  is  relatively 
slight  in  comparison  with  cases  in  which  the  first  sound  is  wholly 


VALVULAR  LESIONS. 


215 


obliterated.  Post-systolic  or  late  systolic  murmurs,  which  are  occa- 
sionally heard  in  mitral  regurgitation,  are  said  to  point  to  a  rela- 
tively slight  amount  of  disease  in  the  valve  (see  Fig.  122).  Rosen- 


1st 


I 


2nd 


1st 


2nd 


FIG.  124.-Late  Systolic  Murmur.   The  first  sound  is  clear  and  an  interval  intervenes  between 

it  and  the  murmur. 

bach  claims  that  the  late  systolic  murmur  is  always  due  to  organic 
disease  of  the  valves  and  never  occurs  as  a  functional  murmur. 

When  compensation  fails,  the  murmur  may  altogether  disappear 
for  a  time,  and  if  the  patient  is  then  seen  for  the  first  time  and 
dies  without  rallying  under  treatment,  it  may  be  impossible  to 


Pulmonic  second 
accented. 


Systolic  murmur 
loudest  here. 


FIG.  125.— Mitral  Regurgitation.    The  murmur  is  heard  over  the  shaded  area  as  well  as  in  the 

back. 

make  the  diagnosis.    The  very  worst  cases,  then,  are  those  in  which 
there  is  no  murmur  at  all. 

The  murmur  of  mitral  regurgitation  is  conducted  in  all  directions, 
but  especially  toward  the  axilla  and  to  the  back  (not  around  the 
chest,  but  directly).  In  the  latter  situation  it  is  usually  louder 


216 


PHYSICAL   DIAGNOSIS. 


than  it  is  in  mid-axilla,  and  occasionally  it  is  heard  as  loudly  in  the 
back  as  anywhere  else.  This  is  no  doubt  owing  to  the  positir  of 
the  left  auricle  (see  Figs.  125  and  126). 

(£)  After  compensation  is  established  and  as  long  as  it  lasts  an 
accentuation  of  the  pulmonic  second  sound  is  almost  invariably  to 
be  made  out,  and  may  be  so  marked  that  we  can  feel  and  see  it,  as 
well  as  hear  it.  Not  infrequently  one  can  also  see  and  feel  the 
pulsation  of  the  conus  arteriosus — not  the  left  auricle — in  the  second 
and  third  left  intercostal  space.  (It  may  be  well  to  mention  again 


Systolic  murmur. 


FIG.  126.— Mitral  Regurgitatlon.    Murmur  heard  over  the  shaded  area. 

here  that  by  accentuation  of  the  pulmonic  second  sound  one  does 
not  mean  merely  that  it  is  louder  or  sharper  in  quality  than  the 
aortic  second  sound,  since  this  is  true  in  the  vast  majority  of  cases 
in  healthy  individuals  under  thirty  years  of  age.  Pathological  ac- 
centuation of  the  pulmonic  second  sound  means  a  greater  intensity 
of  the  sound  than  we  have  a  right  to  expect  at  the  age  of  the  individ- 
ual in  question.)  Occasionally  the  pulmonic  second  sound  is  redu- 
plicated, but  as  a  rule  this  points  to  an  accompanying  stenosis  of 
the  mitral  valve.  At  the  apex  the  second  sound  (i.e.,  the  trans- 
mitted aortic  second)  is  feeble  or  even  wanting  altogether,  owing 


VALVULAR  LESIOXS.  217 

co  the  relatively  small  amount  of  blood  which  recoils  upon  the 
a  or""1,  valves. 

(c)  Enlargement  of  the  heart,  and  more  especially  of  the  right 
ventricle,  is  generally  to  be  made  out,  and  in  the  majority  of  cases 
this  enlargement  is  manifested  by  displacement  of  the  apex  impulse 
both  downward  and  toward  the  left,  but  more  especially  to  the 
left.     Percussion  confirms  the  results  of  inspection  and  palpation 
regarding  the  position  of  the  cardiac  impulse.     The  normal  sub- 
sternal  dulness  is  increased  in  intensity,  and  we  can  sometimes 
demonstrate  an  enlargement  of  the  heart  toward  the  right  (see 
Fig.  123). 

In  children  (in  whom  adhesive  pericarditis  often  complicates 
the  disease)  a  systolic  THRILL  may  not  infrequently  be  felt  at  the 
apex,  and  the  precordia  may  be  bulged,  and  even  in  adults  such  a 
systolic  thrill  is  not  so  rare  as  some  writers  would  have  us  sup- 
pose. 

(d)  The  pulse,  as  said  above,  shows  nothing  characteristic  at  any 
stage  of  the  disease.     While  compensation  lasts,  there  is  usually 
nothing  abnormal  about  the  pulse,  although  it  may  be  somewhat 
irregular  in  force  and  rhythm,  and  may  be  weak  when  compared  to 
the  powerful  beat  at  the  apex  in  case  the  regurgitant  stream  is  a 
very  large  one.     Irregularity  at  this  period  is  less  common  in  pure 
mitral  regurgitation  than  in  cases  complicated  by  stenosis. 

(c)  Third  Stage — Failing  Compensation. 

When  compensation  begins  to  fail,  the  pulse  becomes  weak  and 
irregular,  and  many  heart  beats  fail  to  reach  the  wrist,  but  there 
is  still  nothing  characteristic  about  the  pulse,  which  differs  in  no 
respect  from  that  of  any  case  of  cardiac  weakness  of  whatever 
nature. 

(e)  Evidence  of  venous  stasis,  first  in  the  lungs  and  later  in  the 
liver,  lower  extremities,  and  serous  cavities,  does  not  show  itself 
so  long  as  compensation  is  sufficient,  but  when  the  heart  begins  to 
fail  the  patient  begins  to  complain  not  only  of  palpitation  and  car- 
diac distress,  but  of  dyspnoea,  orthopnoea,  and  cough,  and  examina- 
tion  reveals  a  greater  or  lesser  degree  of  cyanosis  with  pulmo- 


218  PHYSICAL  DIAGNOSIS 

nary  oedema  manifested  by  crackling  rales  at  the  base  of  the  lungs 
posteriorly,  and  possibly  also  by  haemoptysis  or  by  evidences  of 
hydrothorax  (see  below,  p.  330).  If  compensation  is  not  re-estab- 
lished, the  right  ventricle  dilates,  the  tricuspid  becomes  incompe- 
tent, the  liver  becomes  enlarged  and  tender,  dropsy  becomes  gen- 
eral, the  heart  and  pulse  become  more  and  more  rapid  and  irregular, 
the  heart  murmur  disappears  and  is  replaced  by  a  confusion  of 
short  valvular  sounds,  "gallop  rhythm"  or  "delirium  cordis,"  often 
considerably  obscured  by  the  noisy,  labored  breathing  with  numer- 
ous moist  rales.  In  a  patient  seen  for  the  first  time  in  such  a  con- 
dition diagnosis  may  be  impossible,  yet  mitral  disease  of  some  type 
may  usually  be  suspected,  since  murmurs  produced  at  the  aortic 
valve  are  not  so  apt  to  disappear  when  compensation  fails.  The 
relative  tricuspid  insufficiency  which  often  occurs  is  likely  to  mani- 
fest itself  by  an  enlargement  of  the  right  auricle,  sometimes  demon- 
strable by  percussion  and  later  by  venous  pulsation  in  the  neck  and 
in  the  liver. 

(d)  Differential  Diagnosis. 

The  murmur  of  mitral  regurgitation  may  be  confused  with 

(1)  Tricuspid  regurgitation. 

(2)  Functional  murmurs. 

(3)  Stenosis  or  roughening  of  the  aortic  valves. 

(1)  The  post-mortem  records  of  the  Massachusetts  General 
Hospital  show  that  in  the  presence  of  a  murmur  due  to  mitral  re- 
gurgitation it  is  very  easy  to  fail  altogether  to  recognize  a  tricuspid 
regurgitant  murmur.  Only  5  out  of  29  cases  of  tricuspid  regurgi- 
tation found  at  autopsy  were  recognized  during  life.  Allbutt's 
figures  from  Guy's  Hospital  are  similar.  In  the  majority  of  these 
cases,  mitral  regurgitation  was  the  lesion  on  which  attention  was 
concentrated  during  the  patient's  life.  This  is  all  the  more  excus- 
able because  the  tricuspid  area  is  so  wide  and  uncertain.  Murmurs 
produced  at  the  tricuspid  orifice  are  sometimes  heard  with  maxi- 
mum intensity  just  inside  the  apex  impulse,  and  if  we  have  also  a 
mitral  regurgitant.  murmur,  it  may  be  impossible  under  such  cir- 
cumstances to  distinguish  it  from  the  tricuspid  murmur.  Some- 


VALVULAR  LESIONS  219 

times  the  two  are  of  different  pitch,  but  more  often-  tricuspid  regur- 
gitation  must  be  recognized  indirectly  if  at  all,  i.e.,  through  the 
evidence  given  by  venous  pulsation  in  the  jugular  veins  and  in  the 
liver.  Tricuspid  murmurs  are  not  transmitted  to  the  left  axilla 
and  do  not  cause  accentuation  of  the  pulmonic  second  sound,  al- 
though they  are  compatible  with  such  accentuation.  They  are  to 
be  distinguished  from  the  murmurs  of  mitral  regurgitation  by  their 
different  seat  of  maximum  intensity,  possibly  by  a  difference  in 
pitch,  but  most  clearly  by  the  concomitant  phenomena  of  venous 
pulsation  above  mentioned. 

(2)  "  Functional "  murmurs  are  usually  systolic  and  may  have 
their  maximum  intensity  at  the  apex  of  the  heart,  but  in  the  great 
majority  of  cases  they  are  heard  best  over  the  pulrnonic  valve  or 
just  inside  or  outside  the  apex  beat  (Potain).     They  are  faint  or 
inaudible    at  the   end  of   expiration,  and   are  more  influenced  by 
position  than  organic  murmurs  are.     In  the  upright  position  they 
are  often  very  faint.      They  are   rarely  transmitted  beyond  the 
precordia  and  are  unaccompanied  by  any  evidences  of  enlargement 
of  the  heart,  by  any  pathological   accentuation  of  the   pulmonic 
second  sound,1  or  any  evidences  of  engorgement  of  the  lungs  or 
general  venous  system. 

(3)  Roughening  or  narrowing  of  the  aortic  valves  may  produce 
a  systolic  murmur  with  maximum  intensity  in  the  second  right  in- 
tercostal space,  but  this  murmur  is  not  infrequently  heard  all  over 
the  precordia  and  quite  plainly  at  the  apex,  so  that  it  may  simulate 
the  murmur  of  mitral  regurgitation.     The  aortic  murmur  may  in- 
deed be  heard  more  plainly  at  the  apex  than  at  any  other  point  ex- 
cept the  second  right  intercostal  space,  owing  to  the  fact  that  the 
right  ventricle,  which  occupies  most  of  the  precordial  region  be- 
tween the  aortic  and  mitral  areas,  does  not  lend  itself  well  to  the 
propagation  of  certain  types  of  cardiac  murmurs.      Under  these 
circumstances  "  a  loud,  rough  aortic  murmur  may  be  heard  at  the 

1  It  must  be  remembered  that  in  chlorosis,  a  disease  in  which  functional 
murmurs  are  especially  prone  to  occur,  the  pulmonic  second  sound  is  often 
surprisingly  loud,  owing  to  a  retraction  of  the  left  lung,  which  uncovers  the 
root  of  the  pulmonic  artery. 


220  PHYSICAL  DIAGNOSIS. 

apex  as  a  smooth  murmur  of  a  different  tone  "  (Broadbent) .  Such 
a  murmur  is  not,  however,  likely  to  be  conducted  to  the  axilla  or 
heard  beneath  the  left  scapula,  nor  to  be  accompanied  by  accentua- 
tion of  the  pulnionic  second  sound  nor  evidences  of  engorgement 
of  the  lungs  and  general  venous  system. 

II.  MITRAL  STENOSIS. 

Narrowing  or  obstruction  of  the  mitral  orifice  is  almost  invari- 
ably the  result  of  a  chronic  endocarditis  which  gradually  glues  to- 
gether the  two  flaps  of  the  valve  until  only  a  funnel-shaped  open- 
ing or  a  slit  like  a  buttonhole  is  left  see  Figs.  (127  and  128).  As  we 
examine  post  mortem  the  tiny  slit  which  may  be  all  that  is  left  of 
the  mitral  orifice  in  a  case  of  long  standing,  it  is  difficult  to  con- 
ceive how  sufficient  blood  to  carry  on  the  needs  of  the  circulation 
could  be  forced  through  such  an  insignificant  opening. 

Usually  a  slow  and  gradually  developed  lesion,  mitral  stenosis 
often  represents  the  later  stages  of  a  process  which  in  its  earlier 
phases  produced  pure  mitral  re  gurgitation.  By  some  observers  the 
advent  of  stenosis  is  regarded  as  representing  an  attempt  at  com- 
pensation for  a  reduction  of  the  previous  mitral  leakage.  Others 
consider  that  the  stenosis  simply  increases  the  damage  which  the 
valve  has  suffered. 

A  remarkable  fact  never  satisfactorily  explained  is  the  predilec- 
tion of  mitral  stenosis  for  the  female  sex.1  A  large  proportion  of 
the  cases — seventy-six  per  cent  in  my  series — occur  in  women. 

It  is  also  curious  that  so  many  cases  are  associated  with  pul- 
monary tuberculosis. 

Physical  Signs. 

Mitral  stenosis  may  exist  for  many  years  without  giving  rise  to 
any  physical  signs  by  which  it  may  be  recognized,  and  even  after 
signs  have  begun  to  show  themselves  they  are  more  fleeting  and 
inconstant  than  in  any  other  valvular  lesion  of  the  heart.  In  the 
early  stages  of  the  disease  the  heart  may  appear  to  be  entirely  nor- 

1  Fenwick's  explanation,  viz.,  that  the  sedentary  life  of  women  favors 
the  slow  adhesive  inflammation  of  the  valve  and  its  curtains,  resulting  in 
stenosis,  does  not  seem  to  me  to  be  satisfactory. 


VALVULAR  LESIONS. 


221 


mal  if  the  patient  is  at  rest,  and  especially  if  examined  in  the  re- 
curnbent  position,  characteristic  signs  being  elicited  only  by  exer- 
tion ;  or  again  a  murmur  which  is  easily  audible  with  the  patient 
in  the  upright  position  may  disappear  in  the  recumbent  position ; 
or  a  murmur  may  be  heard  at  one  visit,  at  the  next  it  may  be  im- 


FIG.  128. 


FIG.  127.— Diagram  to  Represent  the  Position  of  the  Valves  in  the  Normal  Heart  during  Diastole, 
the  Open  Mitral  Allowing  the  Blood  to  Flow  Down  from  the  Left  Auricle,  the  Aortic  Closed. 

FIG.  128.— Mitral  Stenosis— Period  of  Diastole.    The  blood  (lowing  from  the  left  auricle  is  ob- 
structed by  the  thickened  and  adherent  mitral  curtains. 


222 


PHYSICAL  DIAGNOSIS. 


passible  to  elicit  it  by  any  manoeuvre,  while  at  the  third  visit  it  may 
be  easily  heard  again.  These  characteristics  explain  to  a  certain 
extent  the  fact  that  differences  of  opinion  so  often  arise  regarding 
the  diagnosis  of  mitral  stenosis,  and  that  out  of  forty-eight  cases  in 
which  this  lesion  was  found  at  autopsy  at  the  Massachusetts  General 
Hospital,  only  twenty-three  were  recognized  during  life.  No  com- 
mon lesion  (with  the  exception  of  tricuspid  regurgitation)  has  been 
so  frequently  overlooked  in  our  records. 

I  shall  follow  Broadbent  in  dividing  the  symptoms  into  three 
stages,  according  to  the  extent  to  which  the  lesion  has  progressed. 


In  the  first  stage  inspection  and  palpation  show  that  the  apex 
beat  is  little  if  at  all  displaced,  and  percussion  reveals  no  increase 


Pulmonic  second 
accented. 


"  Double-snock 1 
sound. 


Presystolic  murmur 
heard  in  limited 
area. 


FIG.  129.— Mitral  Stenosis. 


in  the  area  of  cardiac  dulness;  there  is  often  local  tenderness  to  be 
elicited  near  the  apex.  If  one  lays  the  hand  lightly  over  the  origin 
of  the  apex  beat,  one  can  generally  feel  the  purring presystollc  <'///•/// 
which  is  so  characteristic  of  this  disease,  more  common  indeed  than 
in  any  other.  This  thrill  is  more  marked  in  the  second  stage  of 
the  disease,  but  can  generally  be  appreciated  even  in  the  first.  It 
runs  up  to  and  ceases  abruptly,  with  the  very  sharp  first  sound, 


VALVULAR  LESIONS.  223 

the  sudden  shock  of  which  may  be  appreciated  even  by  palpation. 
The  thrill  is  sometimes  palpable  even  when  no  murmur  can  be 
heard,  and  often  the  thrill  is  transmitted  to  the  axilla  when  the 
murmur  is  confined  tc  the  apex  region.  On  auscultation  one 
hears,  especially  after  the  patient  has  been  exerting  himself,  and 
particularly  if  he  leans  forward  and  to  the  left,  a  short  low-pitched 
rumble  or  roll  immediately  preceding  the  systole  and  increasing 
in  intensity  as  it  approaches  the  first  sound.  At  this  stage  of 
the  disease  the  second  sound  can  still  be  heard  at  the  apex.  The 
first  sound  is  very  sharply  accented  or  snapping,  and  communi- 
cates a  very  decided  shock  to  the  ear  when  a  rigid  stethoscope 
is  used.  As  a  rule,  the  murmur  is  closely  confined  to  the  region 
of  the  apex  beat  and  not  transmitted  any  considerable  distance  in 
any  direction.  I  have  seen  cases  in  which  it  was  to  be  heard  only 


2nd 


I 


1st 


2nd 


I 


FIG.  130.— The  Murmur  of  Mitral  Stenosis— First  Stage.  The  place  of  the  murmur  and  its  cres- 
cendo character  are  indicated  by  the  position  of  the  light  lines  just  before  the  first  sound 
and  by  their  increasing  length. 

over  an  area  the  size  of  a  half-dollar.1  Very  characteristic  of  mi- 
tral stenosis  is  a  prolongation  of  the  diastolic  pause  so  that  the  inter- 
val between  the  second  sound  of  one  cycle  and  the  first  sound  of  the 
next  is  unduly  long.  The  pulmonic  second  sound  is  accented  and 
sometimes  reduplicated  ("double-shock  sound" — Sansom)  at  this 
stage  of  the  disease,  but  this  doubling  is  much  more  frequent  later.2 
Irregularity  of  the  heart  beat  both  in  force  and  rhythm  is  very 
frequently  present  even  in  the  early  stages  of  the  affection.  The 
heart  may  be  regular  while  the  patient  is  at  rest,  but  slight  exer- 
tion is  often  sufficient  to  produce  marked  irregularity. 

1  It  may,  however,  be  widely  transmitted  to  the  left  axilla  and  audible  in 
the  back  or  even  over  the  whole  of  the  left  chest,  especially  when  the  stenosis 
is  combined  with  regurgitation. 

2  This  is  the  opinion  of  most  observers.     Sansom  states  that  the  "double- 
shock  sound"  may  precede  ail  other  evidences  of  mitral  stenosis. 


224  PHYSICAL  DIAGNOSIS. 

II. 

In  the  second  stage  the  murmur  and  thrill  are  usually  longer  and 
may  occupy  the*  whole  of  diastole,  beginning  with  considerable  in- 
tensity just  after  the  reduplicated  second  sound,  quickly  diminish- 

1st 


I 


FIG.  131.— Type  of  Presystolic  Murmur  Often  Heard  in  the  Second  Stage  of  Mitral  Stenosis. 
Here  the  murmur  nils  the  whole  of  diastole,  with  a  gradual  increase  of  intensity  as  it  ap- 
proaches the  first  sound.  No  second  sound  is  audible  at  the  apex. 

ing  until  it  is  barely  audible,  and  then  again  increasing  with  a 
steady  crescendo  up  to  the  first  sound  of  the  next  cycle.1  These 
changes  may  be  graphically  represented  as  in  Figs.  130  and  131.  Dia- 
stole is  now  still  more  prolonged,  so  that  the  characteristic  rhythm 
of  this  lesion  is  even  more  marked  than  in  the  earlier  stages  of  the 
disease.  In  many  cases  at  this  stage  no  second  sound  is  to  be  heard 
at  all  at  the  apex,  although  at  the  pulmonic  orifice  it  is  loud  and 
almost  invariably  double.  (This  is  one  of  the  reasons  for  believing 
that  the  second  sound  which  we  usually  hear  at  the  apex  is  the 
transmitted  aortic  second  sound.  In  mitral  disease  the  aortic  valves 


2nd 

FIG.  132.— Type  of  Presystolic  Murmur  Sometimes  Heard  in  the  Second  Stage  of  Mitral  Stenosis. 
There  is  a  double  crescendo.    The  secoud  sound  seems  reduplicated. 

shut  feebly  owing  to  the  relatively  small  amount  of  blood  that  is 
thrown  into  the  aorta.) 

At  this  stage  of  the  disease  enlargement  of  the  heart  begins  to 
make  itself  manifest.     Th    apex  impulse  is  displaced  to  the  left — 

1  Rarely  one  finds  a  crescendo  in  the  middle  of  a  long  presystolic  roll  with 
a  diminuendo  as  it  approaches  the  first  sound. 


VALVULAR  LESIONS.  225 

sometimes  as  far  as  the  mid-axillary  line,  and  often  descends  to 
the  sixth  interspace.  Occasionally  the  cardiac  dulness  is  increased 
to  the  right  of  the  sternum. 

The  instability  and  fleeting  character  of  the  murmur  in  the  ear- 
lier stages  of  the  disease  are  much  less  marked  in  this,  the  second 
stage.  The  first  sound  at  the  apex  still  retains  its  sharp,  thump- 
ing quality,  and  is  often  audible  without  thv  murmur  in  the  back. 

The  irregularity  of  the  heart  is  generally  greater  at  this  stage 
than  in  the  earlier  one. 

III. 

The  third  stage  of  the  affection  is  marked  by  the  disappearance 
of  the  characteristic  murmur,  and  is  generally  synchronous  with 
the  development  of  tricuspid  re  gurgitation.  The  right  ventricle 
becomes  dilated  sometimes  very  markedly.  Indeed,  it  may  produce 
a  visible  pulsating  tumor  below  the  left  costal  border  and  be  mis- 
taken for  cardiac  aneurism  (Osier).  The  snapping  first  sound  and 
the  "  double-shock  "  sound  usually  remain  audible,  but  the  latter 
may  be  absent  altogether.  Diagnosis  in  this  stage  rests  largely  upon 
the  peculiar  snapping  character  of  the  first  sound,  together  with  the 
prolongation  of  diastole  and  the  very  great  irregularity  of  the  heart, 
both  in  force  and  rhythm.  At  times  a  presystolic  thrill  may  be 
felt  even  when  no  murmur  is  to  be  heard. 

The  pulse  shows  nothing  characteristic  in  many  cases  except 
that  early  and  persistent  irregularity  which  has  been  already  al- 
luded to.  In  other  cases  the  wave  is  low,  long,  easily  compressed, 
but  quite  perceptible  between  beats ;  but  for  the  lack  of  sufficient 
power  in  the  cardiac  contractions  the  pulse  would  be  one  of  high 
tension. 

As  the  disease  advances  the  irregularity  of  the  pulse  becomes 
more  and  more  marked,  and  sometimes  presents  an  amazing  contrast 
with  the  relatively  good  general  condition  of  the  circulation.  Even 
when  not  more  than  a  third  of  the  beats  reach  the  wrist,  the  patient 
may  be  able  to  attend  to  light  work  and  feel  very  well.  Such  cases 
make  us  feel  as  if  a  pulse  were  a  luxury  rather  than  a  necessity. 

Under  the  influence  of  digitalis  the  pulse  is  especially  apt  to 
15 


226  PHYSICAL  DIAGNOSIS. 

assume  the  bigeminal  type  in  mitral  stenosis.  Every  other  beat  is 
then  so  abortive  that  it  fails  to  send  a  wave  to  the  wrist,  and  the 
weak  beat  is  succeeded  by  a  pause.  According  to  Broadbent  the 
weak  beat  corresponds  to  an  abortive  contraction  of  the  left  ven- 
tricle accompanied  by  a  normal  contraction  of  the  right  ventricle, 
so  that  for  each  two  strong  beats  of  the  right  side  of  the  heart  we 
have  one  strong  and  one  weak  beat  of  the  left  side  of  the  heart. 

Mitral  stenosis  is  in  the  great  majority  of  cases  combined  with 
mitral  regurgitation,  and  it  often  happens  that  the  signs  of  regur- 
gitation  are  so  much  more  prominent  than  those  of  stenosis  that 
the  latter  escape  observation  altogether,  especially  in  the  third 
stage  of  the  disease,  when  the  typical  presystolic  roll  has  disap- 
peared. In  such  cases  combined  stenosis  and  regurgitation  is  to  be 
distinguished  from  pure  regurgitation  by  the  sharpness  of  the  first 
sound,  which  would  be  very  unusual  at  this  stage  of  a  case  of  pure 
mitral  regurgitation.  The  presence  of  reduplicated  second  sound,  a 
"  double-shock  sound  "  at  the  outset  of  the  prolonged  diastolic  pause, 
and  of  great  irregularity  in  force  and  rhythm,  is  further  suggestive 
of  mitral  stenosis. 

Mitral  stenosis  is  apt  to  be  associated  with  haemoptysis,  with  en- 
gorgement of  the  liver  and  ascites,  and  especially  with  arterial  em- 
bolism. No  other  valve  lesion  is  so  frequently  found  associated 
with  embolism.  The  lungs  are  generally  very  voluminous,  and 
may  therefore  mask  an  increase  in  area  or  intensity  of  the  cardiac 
dulness. 

Differential  Diagnosis. 

I  have  already  discussed  the  difficulty  of  distinguishing  a  double 
lesion  at  the  mitral  valve  from  a  simple  mitral  regurgitation  (see 
above,  p.  215) 

Other  murmurs  which  may  be  mistaken  for  the  murmur  of  mi- 
tral stenosis  are : 

(a)  The  Austin  Flint  murmur. 

(J)  The  murmur  of  tricuspid  stenosis. 

(c)  A  rumbling  murmur  sometimes  heard  in  children,  after  an 
attack  of  pericarditis. 


VALVULAR  LESIONS.  227 

(a)  The  Austin  Flint  murmur. 

In  1862  Austin  Flint  studied  two  cases  in  which  during  life  a 
typical  presystolic  roll  was  audible  at  the  apex  of  the  heart,  yet  in 
which  post  mortem  the  mitral  valve  proved  to  be  perfectly  normal, 
and  the  only  lesion  present  was  aortic  insufficiency.  This  observation 
has  since  been  verified  by  Osier,  Brain  well,  Gairdner,  and  other  com- 
petent observers.  At  the  Massachusetts  General  Hospital  we  have 
had  seven  such  cases  with  autopsy.  Yet,  despite  repeated  confir- 
mation, Flint's  observation  has  remained  for  nearly  forty  years  un- 
known to  physicians  at  large.  Its  importance  is  this :  Given  a  case 
of  aortic  regurgitation — a  presystolic  murmur  at  the  apex  does  not 
•  necessarily  mean  stenosis  of  the  mitral  valve  even  though  the  mur- 
mur has  the  typical  rolling  quality  and  is  accompanied  by  a  pal- 
pable thrill.  It  may  be  only  one  of  the  by-effects  of  the  aortic 
incompetency.  How  it  is  that  a  presystolic  murmur  can  be  pro- 
duced at  the  apex  in  cases  of  aortic  regurgitation  has  been  much 
debated.  Some  believe  it  is  due  to  the  impact  of  the  aortic  regur- 
gitant  stream  upon  the  ventricular  side  of  the  mitral  valve,  floating 
it  out  from  the  wall  of  the  ventricle  so  as  to  bring  it  into  contact 
with  the  stream,  of  blood  descending  from  the  left  auricle.  Others 
suppose  that  the  mingling  of  the  two  currents  of  blood,  that  from 
the  mitral  and  that  from  the  aortic  orifice,  is  sufficient  to  produce 
the  murmur. 

Between  the  "  Austin  Flint  murmur  "  thus  defined  and  the  mur- 
mur of  true  mitral  stenosis,  complicating  aortic  regurgitation,  diag- 
nosis may  be  impossible.  If  there  is  no  dilatation  of  the  mitral 
orifice  and  no  regurgitation,  either  from  this  cause  or  from  deformi- 
ties of  the  mitral  valve  itself,  any  evidence  of  engorgement  of  the 
pulmonary  circuit  (accentuation  of  the  pulrnonic  second  sound, 
oedema  of  the  lungs,  haemoptysis,  and  cough)  speaks  in  favor  of  an 
actual  narrowing  of  the  mitral  valve,  while  the  absence  of  such 
signs  and  the  presence  of  a  predominating  hypertrophy  of  the  left 
ventricle  tend  to  convince  us  that  the  murmur  is  of  the  type  de- 
scribed by  Austin  Flint,  i.e.,  that  it  does  not  point  to  any  sten- 
osis of  the  mitral  valve.  The  sharp,  snapping  first  sound  and 
systolic  shock  so  characteristic  of  mitral  stenosis  are  said  to  be 


228  PHYSICAL  DIAGNOSIS. 

modified  or  absent  in  connection  with  murmurs  of  the  Austin  Flint 
type. 

(J)  Tricuspid  obstruction. 

Luckily  for  us  as  diagnosticians,  stenosis  of  the  tricuspid  valve 
is  a  very  rare  lesion.  Like  mitral  stenosis  it  is  manifested  by  a 
presystolic  rolling  murmur  whose  point  of  maximum  intensity  is 
sometimes  over  the  traditional  tricuspid  area,  but  may  be  at  a  point 
so  near  the  mitral  area  as  to  be  easily  confused  with  stenosis  cf 
the  latter  valve. 

The  difficulty  of  distinguishing  tricuspid  stenosis  from  mitral 
stenosis  is  further  increased  by  the  fact  that  the  two  lesions  almost 
invariably  occur  in  conjunction.  Hence  we  have  two  presystolic 
murmurs,  perhaps  with  slightly  different  points  of  maximum  inten- 
sity and  possibly  with  a  difference  in  quality,  but  often  quite  un- 
distinguishable  from  each  other.  In  the  vast  majority  of  cases, 
therefore,  tricuspid  stenosis  is  first  recognized  at  the  autopsy,  and 
the  diagnosis  is  at  best  a  very  difficult  one. 

(c)  Broadbent,  Rosenbach,  and  others  have  noticed  in  children 
who  have  just  passed  through  an  attack  of  pericarditis  a  rumbling 
murmur  near  the  apex  of  the  heart,  which  suggests  the  murmur  oi 
mitral  stenosis.  It  is  distinguished  from  the  latter,  however,  by  the 
absence  of  any  accentuation  of  the  first  sound  at  the  apex,  as  well 
as  by  the  conditions  of  its  occurrence  and  by  its  transiency.  Such 
cases  are  important,  since  their  prognosis  is  much  more  favorable 
than  that  of  mitral  stenosis. 

Phear  (Lancet,  September  21,  1895)  investigated  46  cases  in 
which  a  presystolic  murmur  was  observed  during  life  and  no  mitral 
lesion  found  at  autopsy.  In  17  of  these  there  was  aortic  regurgi- 
tation  at  autopsy ;  in  20  of  these  there  was  adherent  pericardium 
at  autopsy ;  in  9  nothing  more  than  dilatation  of  the  left  ventricle 
was  found.  In  none  of  these  cases  was  the  snapping  first  sound, 
so  common  in  mitral  stenosis,  recorded  during  life. 

It  should  be  remembered  that  patients  suffering  from  mitral 
stenosis  are  very  frequently  unaware  of  any  cardiac  trouble,  and 
seek  advice  for  anaemia,  wasting,  debility,  gastric  or  pulmonary 
complaints.  This  is  less  often  true  in  other  forms  of  valvular  dis- 


VALVULAR  LESIONS.  229 

ease.  "We  should  be  especially  on  our  guard  in  cases  of  supposed 
"nervous  arrhythmia"  or  "tobacco  heart,"  if  there  has  been  an  at- 
tack of  rheumatism  or  chorea  previously.  Such  cases  may  present 
no  signs  of  disease  except  the  irregularity — yet  may  turn  out  to 
be  mitral  stenosis. 

IV.  AORTIC  REGURGITATIOX. 

Rheumatic  endocarditis  usually  occurs  in  early  life  and  most 
often  attacks  the  mitral  valve.  The  commonest  cause  of  aortic  dis- 
ease on  the  other  hand — arterio-sclerosis — is  a  disease  of  late  mid- 


FIG.  133.— Diastole  in  Aortif  Kt-gu rotation.    The  blood  is  flowing  back  through  the  stumpy  and 
incompetent  aortic  valves. 

die  life,  and  attacks  men  much  more  often  than  women.  When 
we  think  of  aortic  regurgitation,  the  picture  that  rises  before  us  is 
usually  that  of  a  man  past  middle  life  and  most  often  from  the 
classes  who  live  by  manual  labor.  Nevertheless  cases  occur  at  all 
ages  and  in  both  sexes,  and  rheumatic  endocarditis  does  not  spare 
the  aortic  cusps  altogether  by  any  means. 

Whether  produced  by  arterio-sclerosis  extending  down  from  the 
aorta,  or  by  rheumatic  or  septic  endocarditis,  the  lesion  which  re- 
sults in  aortic  regurgitation  is  usually  a  thickening  and  shortening 
of  the  cusps  (see  Fig.  133).  In  rare  cases  an  aortic  cusp  may  be 
ruptured  as  a  result  of  violent  muscular  effort,  and  the  signs  and 


230  PHYSICAL  DIAGNOSIS. 

symptoms  of  regurgitation  then  appear  suddenly.  But  as  a  rule 
the  lesion  comes  on  slowly  and  insidiously,  and  unless  discovered 
accidentally  or  in  the  course  of  routine  physical  examination  it  rnayv 
exist  unnoticed  for  years.  Dropsy  and  cyanosis  are  relatively  late 
and  rare,  and  the  symptoms  which  first  appear  are  usually  those  of 
dyspnoea  and  precordial  distress. 

It  is  a  disputed  point  whether  relative  and  temporary  aortic 
insufficiency  due  to  stretching  of  the  aortic  orifice  ever  occurs.  If 
it  does  occur,  it  is  certainly  exceedingly  rare,  as  the  aortic  ring  is 
very  tough  and  inelastic. 

Dilatation  of  the  aortic  arch—  resembling  diffuse  aneurism — oc- 
curs in  almost  every  case  of  aortic  regurgitation,  and  produces  sev- 
eral important  physical  signs.  This  complication  is  a  very  well- 
known  one,  but  has  not,  I  think,  been  sufficiently  insisted  on  in 
text -books  of  physical  diagnosis.  It  forms  part  of  that  general 
enlargement  of  the  arterial  tree  which  is  so  characteristic  of  the 
disease. 

Physical  Signs. 

Inspection  reveals  more  that  is  important  in  this  disease  than 
in  any  other  valvular  lesion.  In  extreme  cases  the  patient's  face 
or  hand  may  blush  visibly  with  every  systole.  Not  infrequently 
one  can  make  the  diagnosis  across  the  room  or  in  the  street  by  not- 
ing the  violent  throbbing  of  the  carotids,  which  may  be  such  as  to 
shake  the  person's  whole  head  and  trunk,  and  even  the  bed  on 
which  he  lies.  No  other  lesion  is  so  apt  to  cause  a  heaving  of  the 
whole  chest  and  a  bobbing  of  the  head,  and  no  other  lesion  so  often 
causes  a  bulging  of  the  precordia,  for  in  no  other  lesion  is  the  en- 
largement of  the  heart  so  great  (cor  bovinum  or  ox-heart) .  The 
throbbing  of  the  dilated  aorta  can  often  be  felt  and  sometimes  seen 
in  the  suprasternal  notch  or  in  the  second  right  interspace.  Not 
only  the  carotids  but  the  subclavians,  the  brachials  and  radials, 
the  femoral  and  anterior  tibial,  and  even  the  digital  and  dorsalis 
pedis  arteries  may  visibly  pulsate,  and  the  characteristic  jerking 
quality  of  the  pulse  may  be  seen  as  well  as  felt.  This  visible  pul- 
sation in  the  peripheral  arteries,  while  very  characteristic  of  aortic 


VALVULAR  LESIONS. 


231 


regurgitation,  is  occasionally  seen  in  cases  of  simple  hypertrophy  of 
the  heart  from  hard  muscular  work  {e.g.,  in  athletes).  If  the  ar- 
teries are  extensively  calcified,  their  pulsation  become  much  less 
marked. 

The  peculiar  conditions  of  the  circulation  whereby  it  is  "  changed 
into  a  series  of  discontinuous  discharges  as  if  from  a  catapult"  (All- 
butt)  throws  a  great  tensile  strain  upon  all  the  arteries,  and  results, 
in  almost  every  long-standing  case,  in  increasing  both  their  length 


Pulsation  at  the  jugulum. 


Dulness  and  pul- 
sation    cor  re-  ,*• 
spending  to  the 
dilated  aortic 
arch. 


Pulsating  car- 
otids. 


Diastolic  murmur. 


Displaced  cardiax 
Impulse. 


FIG.  I'M.— Aortic  Regurgitation,  Showing  Position  of  the  Diastolic  Murmur  and  Areas  of  Visible 

Pulsation. 

and  their  diameter.  The  visible  arterial  trunks  become  tortuous 
and  distended,  while  the  arch  of  the  aorta  is  diffusely  dilated  so  as 
to  resemble  an  aneurism  (see  Fig.  134).  With  each  heart  beat  the 
snaky  arteries  are  often  jerked  to  one  side  as  well  as  made  to 
throb. 

Inspection  of  the  region  of  the  cardiac  impulse  almost  always 
shows  a  very  marked  displacement  of  the  apex  beat  both  downward 
and  outward  (but  especially  the  former),  corresponding  to  the  hy 
pertrophy  and  still  more  to  the  dilatation  of  the  left  ventricle, 


232  PHYSICAL  DIAGNOSIS. 

which  is  usually  very  great,  and  to  the  downward  sagging  of  the 
enlarged  aorta.  Dilatation  is  in  this  disease  an  essentially  helpful 
and  compensatory  process.  In  a  small  proportion  of  the  cases  no 
enlargement  of  the  heart  is  to  be  demonstrated.  This  was  true  of 
5  out  of  the  last  67  cases  which  I  have  notes  of,  and  generally 
denotes  an  early  and  slight  lesion.  Not  at  all  infrequently  one 
finds  a  systolic  retraction  of  the  interspaces  near  the  apex  beat 
instead  of  a  systolic  impulse.  This  is  probably  due  to  the  negative 
pressure  produced  within  the  chest  by  the  powerful  contraction  of 
an  liypertrophied  heart.  In  the  suprasternal  notch  one  often  feels 
as  well  as  sees  a  marked  systolic  pulsation  transmitted  from  the  arch 
of  the  dilated  aorta,  and  sometimes  mistaken  for  saccular  aneurism. 
Arterial  pulsation  of  the  liver  and  spleen  are  rarely  demon- 
strable by  a  combination  of  sight  and  touch. 

Capillary  Pulsation. 

If  one  passes  the  end  of  a  pencil  or  other  hard  substance  once 
or  twice  across  the  patient's  forehead,  and  then  watches  the  red 
mark  so  produced,  one  can  often  see  a  systolic  flushing  of  the  hyper- 
eemic  area  with  each  beat  of  the  heart.  This  is  by  far  the  best 
method  of  eliciting  this  phenomenon.  It  may  also  be  seen  if  a  glass 
slide  is  pressed  against  the  mucous  membrane  of  the  lip  so  as  par- 
tially to  blanch  it,  or  if  one  presses  upon  the  finger-nail  so  as  par- 
tially to  drive  the  blood  from  under  it ;  but  in  both  these  manoeuvres 
error  may  result  from  inequality  in  the  pressure  made  by  the  ob- 
server upon  the  glass  slide  or  upon  the  nail.  Very  slight  movements 
of  the  observer's  fingers,  even  such  as  are  caused  by  his  own  pulse, 
may  give  rise  to  changes  simulating  capillary  pulsation.  Capillary 
pulsation  of  normal  tissues  is  not  often  seen  in  any  condition  other 
than  aortic1  regurgitation,  yet  occasionally  one  meets  with  it  in 
diseases  which  produce  very  low  tension  of  the  pulse,  such  as 
phthisis  or  typhoid,  anaemic  and  neurasthenic  conditions,  and  I 
have  twice  seen  it  in  perfectly  healthy  persons.  In  such  cases  the 
pulsation  is  usually  less  marked  than  in  aortic  regurgitation. 
Rarely  pulsation  may  be  detected  in  the  peripheral  veins. 

1  Jumping  toothache  and  throbbing  felon  are  common  examples  of  capil- 
lary pulsation  in  inflamed  areas. 


VALVULAR  LESIONS. 


233 


Palpation. 

Palpation  verifies  the  position  of  the  cardiac  impulse  and  the 
heaving  of  the  whole  chest  wall  suggested  by  inspection.  The 
shock  of  the  heart  is  very  powerful  and  deliberate  unless  dilatation 


FIG.  136.— Sphygmographic  Tracing  from  Normal  Pulse. 

is  extreme,  when  it  becomes  wavy  and  diffuse.  In  the  supraclavic- 
ular  notch  a  systolic  thrill  is  often  to  be  felt.  A  diastolic  thrill 
in  the  precordia  is  very  rare. 

The  pulse  is  important,  usually  characteristic.     The  wave  rises 


FlO.  136.— Sphygmograpbic  Tracing  of  the  "  l*ulsus  Celer"  in  Aortic  Regurgitation.    Its  col- 
lapsing character  is  well  shown. 

very  suddenly  and  to  an  unusual  height,  then  collapses  complete!^ 
and  with  great  rapidity  (piilsus  celer)  (see  Figs.  135,  136). 

This  type  of  pulse,  which  is  known  as  the  "  Corrigan  pulse  "  or 
"water-hammer  pulse,"  is  exaggerated  if  one  raises  the  patient's 
arm  above  the  head  so  as  to  make  the  force  of  gravity  aid  in  emp- 
tying the  artery.  The  quality  of  the  pulse  in  aortic  regurgitation 


234  PHYSICAL  DIAGNOSIS. 

is  due  to  the  fact  that  a  large  volume  of  blood  is  suddenly  and  for- 
cibly thrown  into  the  aorta  by  the  hypertrophied  and  dilated  left 
ventricle,  thus  causing  the  characteristically  sharp  and  sudden  rise 
in  the  peripheral  arteries.  The  arteries  then  empty  themselves  in 
two  directions  at  once,  forward  into  the  capillaries  and  backward 
into  the  heart  through  the  incompetent  aortic  valves;  hence  the 
sudden  collapse  in  the  pulse  which,  together  with  its  sharp  and 
sudden  rise,  are  its  important  characteristics.  The  arteries  are 
large  and  often  elongated  so  as  to  be  thrown  into  curves. 

Not  infrequently  one  can  demonstrate  that  the  radial  pulse  is 
delayed  or  follows  the  apex  impulse  after  a  longer  interval  than 
in  normal  persons.  While  compensation  lasts,  the  pulse  is  usually 
regular  in  force  and  rhythm.  Irregularity  is  therefore  an  especially 
grave  sign,  much  more  so  than  in  any  other  valvular  lesion. 

Percussion. 

Percussion  adds  but  little  to  the  information  obtained  by  inspec- 
tion and  palpation,  but  verifies  the  results  of  these  methods  of  in- 
vestigation respecting  the  increased  size  of  the  heart,  and  especially 
of  the  left  ventricle,  which  may  reach  enormous  dimensions,  espe- 
cially in  cases  occurring  in  young  persons.  The  heart  may  be 
increased  to  more  than  four  times  its  normal  weight. 

Auscultation. 

In  rare  cases  there  may  be  absolutely  no  murmur  and  the  diag- 
nosis may  be  impossible  during  life,  though  it  may  be  suspected 
by  reason  of  the  above-mentioned  signs  in  the  peripheral  arteries. 
Unless  the  free  ear  is  used  the  murmur  is  often  so  faint  as  to  be 
easily  overlooked.  This  is  especially  true  in  cases  occurring  in 
elderly  people,  and  when  the  patient  has  been  for  a  considerable 
time  at  rest.  The  difficulty  of  recognizing  certain  cases  of  aortic 
regurgitation  during  life  is  shown  by  the  fact  that  out  of  sixty-five 
cases  of  aortic  regurgitation  demonstrated  at  autopsy  in  the  Massa- 
chusetts General  Hospital,  only  forty-four  were  recognized  during 
life. 


VALVULAR  LESIONS. 


235 


In  the  majority  of  cases,  however,  the  characteristic  diastolie 
murmur  is  easily  heard  if  one  listens  in  the  right  place,  and  when 
heard  it  is  the  most  distinctive  and  trustworthy  of  all  cardiac  mur- 
murs. It  almost  invariably  points  to  aortic  regurgitation  and  to 
nothing  else. 

The  murmur  of  aortic  regurgitation,  as  has  been  already  men- 
tioned, is  diastolio  in  time.'  Its  maximum  intensity  is  usually  not 


FIG.  137.— Position  of  the  Point  of  Maximum  Intensity  of  the  Murmur  of  Aortic  Regurgitation. 
The  dots  are  most  thickly  congregated  where  the  murmur  is  oftenest  heard. 

in  the  conventional  aortic  area  (second  right  interspace),  but  on  the 
left  side  of  the  sternum  about  the  level  of  the  fourth  left  costal  carti- 
lage. In  about  one-tenth  of  the  cases,  and  especially  when  the 
aortic  arch  is  much  dilated,  the  murmur  is  best  heard  in  the  con- 
ventional aortic  area.  Occasionally  there  are  two  points  at  which 
it  may  be  loudly  heard — one  in  the  second  right  interspace  and  the 
other  at  or  outside  the  cardiac  apex,  while  between  these  points 

'Another  murmur,  systolic  in  time,  which  almost  always  accompanies 
the  diastolie  murmur,  is  usually  due  to  roughening  of  the  edges  of  the  aortic 
valves  or  to  dilatation  of  the  aortic  arch.  This  murmur  must  not  be  assumed 
to  mean  aortic  stenosis  (see  below,  p.  243). 


236  PHYSICAL  DIAGNOSIS. 

the  murmur  is  faint.  This  is  probably  due  to  the  fact  that  the 
left  ventricle,  through  which  the  murmur  is  conducted,  approaches 
the  surface  of  the  chest  only  at  the  apex,  while  the  intermediate  space 
is  occupied  by  the  right  ventricle,  which  often  fails  readily  to  trans- 
mit murmurs  produced  at  the  aortic  orifice.  Less  frequently  the 
murmur  of  aortic  regurgitation  is  heard  with  maximum  intensity 
at  the  second  or  third  left  costal  cartilage  or  in  the  region  of  the 
ensiforrn  cartilage  (see  Fig.  137). 

From  its  seat  of  maximum  intensity  (i.e.,  usually  from  the 
fourth  left  costal  cartilage)  the  murmur  is  transmitted  in  all  direc- 
tions, but  not  often  beyond  the  precordia.  In  about  one-third  of 
the  cases  it  is  transmitted  to  the  left  axilla  or  even  to  the  back. 
It  is  sometimes  to  be  heard  in  the  subclavian  artery  and  the 
great  vessels  of  the  neck;  in  other  cases  two  heart  sounds  are 

1st  1st 

2nd 


12nd  | 
111 I 


FIG.  138.  -  Short  Diastolic  Murmur  Not  Replacing  the  Second  Sound. 

audible  in  the  carotid,  but  no  murmur.  The  murmur  is  iisually 
blowing  and  relatively  high  pitched,  sometimes  musical.  Its  inten- 
sity varies  much,  but  is  most  marked  at  the  beginning  of  the  mur- 
mur, giving  the  impression  of  an  accent  there.  It  may  occupy  the 
whole  of  diastole  or  only  a  small  portion  of  it — usually  the  earlier 
portion  (see  Fig.  138).  Late  diastolic  murmurs  are  rare.  The  mur- 
mur may  or  may  not  replace  the  second  sound  of  the  heart.  Broad- 
bent  believes  that  when  it  does  not  obliterate  the  second  sound, 
the  lesion  is  usually  less  severe  than  when  only  the  murmur  is  to 
be  heard.  Allbutt  dissents  from  this  opinion. 

In  listening  for  the  aortic  second  sound  with  a  view  to  gauging 
the  severity  of  the  lesion,  it  is  best  to  apply  the  stethoscope  over  the 
right  carotid  artery,  as  here  we  are  less  apt  to  be  confused  by  the 
murmur  or  by  the  pulmonic  second  sound. 

The  position  of  the  patient's  body  has  but  little  effect  upon  the 
uiurmur — less  than  upon  murmurs  produced  at  the  mitral  orifice. 


VALVULAR  LESIONS.  237 

The  first  sound  at  the  apex  is  generally  dull  and  long.  There 
is  no  accentuation  of  the  pulmonic  second. 

Over  the  larger  peripheral  arteries,  especially  over  the  femoral 
artery,  one  hears  in  most  cases  a  sharp,  short  systolic  sound  ("pis- 
tol-shot sound  ")  due  to  the  sudden  filling  of  the  unusually  empty 
artery ;  this  sound  is  merely  an  exaggeration  of  what  may  be  heard 
in  health.  Pressure  with  the  stethoscope  will  usually  bring  out  a 
systolic  murmur  (as  also  in  health),  and  occasionally  a  diastolic 
murmur  as  well  (Duroziez's  sign).  This  diastolic  murmur  in  the 
peripheral  arteries,  obtained  on  pressure  with  the  stethoscope,  is 
practically  never  heard  except  in  aortic  re  gurgitation.  It  is  thought 
by  some  to  be  due  to  the  regurgitant  current  in  the  great  vessels 
which  in  very  marked  cases  may  extend  as  far  as  the  femoral  ar- 
tery. Duroziez's  sign  is  a  comparatively  rare  one,  not  present  in 
most  cases  of  aortic  regurgitation,  and  usually  disappears  when 
compensation  fails. 

Summary  and  Differential  Diagnosis. 

A  diastolic  murmur  heard  with  the  maximum  intensity  about 
the  fourth  left  costal  cartilage  (less  often  in  the  second  right  inter- 
space) gives  us  almost  complete  assurance  of  the  existence  of  aortic 
regurgitation.  From  mitral  stenosis  and  from  pulmonary  regurgi- 
tation, an  exceedingly  rare  lesion,  the  disease  is  distinguished  by  the 
presence  of  predominating  hypertrophy  of  the  left  ventricle  with  a 
heaving  apex  impulse  and  by  the  following  arterial  phenomena: 

(a)  Visible  pulsation  hi  the  peripheral  arteries. 

(b)  Capillary  pulsation. 

(c)  "  Corrigan  "  pulse. 

(d~)  "  Pistol-shot  sound  "  in  the  femoral  artery. 

(e)  Duroziez's  sign. 

Cardiopulmonary  murmurs  (see  page  197^  are  occasionally  dias- 
tolic, but  are  very  markedly  influenced  by  position  and  by  respira- 
tion, while  aortic  murmurs  are  but  slightly  modified. 

The  very  rare  functional  diastolic  murmur,  transmitted  from  the 
veins  of  the  neck  and  heard  over  the  base  of  the  heart  in  cases  of 
grave  anaemia,  may  be  obliterated  by  pressure  over  the  bulbus  jugu- 
laris.  Such  pressure  has  no  effect  upon  the  murmur  of  aortic  regur- 


238  PHYSICAL  DIAGNOSIS. 

gitation.  I  have  recently  reported  (Johns  Hopkins  Bull.,  May, 
1903)  three  cases  of  intense  anaemia  associated  with  diastolic  mur- 
murs exactly  like  those  of  aortic  regurgitation,  but  proved  post 
mortem  to  be  independent  of  any  valvular  lesion  The  arterial 
phenomena  were  not  marked,  but  the  diagnosis  of  such  cases  is 
very  hard.  Luckily  they  are  rare.  The  origin  is  obscure. 

It  must  be  remembered  that  aortic  regurgitant  murmurs  are 
often  exceedingly  faint,  and  -should  be  listened  for  with  the  greatest 
care  and  under  the  most  favorable  conditions. 

Estimation  of  the  Extent  and  Gravity  of  the  Lesion. 

The  extent  of  the  lesion  is  roughly  proportional  to— 

(a)  The  amount  of  hypertrophy  of  the  left  ventricle. 

(J)  The  degree  to  which  the  pulse  collapses  during  diastole 
(provided  the  radial  is  not  so  much  calcified  as  to  make  collapse 
impossible). 

(c)  The  degree  to  which  the  murmur  replaces  the  second  sound 
as  heard  over  the  right  carotid  artery  (Broadbent). 

Irregularity  of  the  pulse  is  a  far  more  serious  sign  in  this  dis- 
ease than  in  lesions  of  the  mitral  valve,  and  indicates  the  beginning 
of  a  serious  failure  of  compensation. 

Another  grave  sign  is  a  diminution  in  the  intensity  of  the 
murmur. 

Complications. 

(1)  Dilatation  of  the  Aorta. — Diffuse  dilatation  of  the  aortic  arch 
is  usually  associated  with  aortic  regurgitation  and  may  produce  a 
characteristic  area  of  dulness  to  the  right  of  the  sternum  (see  Fig. 
134).     Not  infrequently  this  dilatation  is  the  cause  of  a  systolic 
murmur  to  be  heard  over  the  region  of  the  aortic  arch  and  in  the 
great  vessels  of  the  neck.  N 

(2)  Roughening  of  the  Aortic  Valves. — In  almost  all  cases  of  aortic 
regurgitation  the  valves  are  sufficiently  roughened  to  produce  a 
systolic  murmur  as  the  blood  flows  over  them.     This  murmur  is 
heard  at  or  near  the  conventional  aortic  area,  and  may  be  trans- 
mitted into  the  carotids.     (The  relation  of  these  murmurs  to  the 
diagnosis  of  aortic  stenosis  will  be  considered  with  the  latter  lesion.) 


VALVULAR  LESIONS.  239 

(3)  The  return  of  arterial  blood  through  the  aortic  valves  into 
the  left  ventricle  produces  in  time  both  hypertrophy  and  dilatation 
of  this  chamber,  and  results  ultimately  in  a  stretching  of  the  mitral 
orifice  which  renders  the  mitral  curtains  incompetent.     The  result 
is  a  "  relative  mitral  insufficiency,"  i  e.,  one  in  which  the  mitral  valve 
is  intact  but  too  short  to  reach  across  the  orifice  which  it  is  in- 
tended to  close.     Such  an  insufficiency  of  the  mitral  occurs  in  most 
well-marked  cases ;  it  temporarily  relieves  the  overdistention  of  the 
left  ventricle  and  often  the  accompanying  angina,  although  at  the 
cost  of  engorging  the  lungs. ' 

(4)  The  Austin  Flint  Murmur. — The  majority  of  cases  of  aortic 
regurgitation  are  accompanied  by  a  presystolic  murmur  at  the  apex, 
which  may  be  due  to  a  genuine  mitral  stenosis  or  may  be  produced 
in  the  manner  suggested  by  Austin  Flint.      (For  a  fuller  discussion 
of  this  murmur  see  above,  p.  227- ) 

(5)  Aortic  stenosis  frequently  accompanies  cases  of  aortic  re- 
gurgitation,  especially  in  the  rheumatic  and  choreic  and  septic  types 
occurring  in  young  persons.     It  has  the  effect  of  increasing  the  in- 
tensity of  the  diastolic  murmur,  since  the  regurgitating  stream  has 
to  pass  through  a  smaller  opening. 

The  excessive  arterial  pulsation  may  be  less  marked  if  stenosis 
accompanies  regurgitation,  but  this  is  not  always  the  case  (see 
below,  p.  243). 


AORTIC  STENOSIS. 

Uncomplicated  aortic  stenosis  is  by  far  the  rarest  of  the  valvu- 
lar lesions  of  the  left  side  of  the  heart,  as  well  as  the  most  difficult 
to  recognize*  Out  of  two  hundred  and  fifty-two  autopsies  made  at 
the  Massachusetts  General  Hospital  in  cases  of  valvular  disease 
there  was  not  one  of  uncomplicated  aortic  stenosis.  Twenty-nine 
cases  occurred  in  combination  with  aortic  regurgitation.  During 
life  the  diagnosis  of  aortic  stenosis  is  frequently  made,  but  often  on 
insufficient  evidence — i.e.,  upon  the  evidence  of  a  systolic  murmur 
heard  with  maximum,  intensity  in  the  second  right  intercostal  space 

1  This  relative  insufficiency  of  the  mitral  valve  has  been  termed  its  "safety- 
vahe"  action,  but  the  safety  is  but  temporary  and  dearly  bought. 


240  PHYSICAL  DIAGNOSIS. 

and  transmitted  into  the  vessels  of  the  neck.  Such  a  murmur  does 
indeed  occur  in  aortic  stenosis,  but  is  by  no  means  peculiar  to  this 
condition.  Of  the  other  diseases  which  produce  a  similar  murmur 
more  will  be  said  under  Differential  Diagnosis. 

For  the  diagnosis  of  aortic  stenosis  we  need  the  following  evi- 
dence : 

(1)  A  systolic  murmur  heard  best  in  the  second  right  intercostal 
space  and  transmitted  to  the  neck. 

(2)  The  characteristic  pulse  (vide  infra). 

(3)  A  palpable  thrill  (usually). 

(4)  Absence  or  great  enfeeblement  of  the  aortic  second  sound.1 
Of  these  signs  the  characteristic  pulse  is  the  most  important. 


FIG.  138.— Aortic  Stenosis.    The  heart  is  in  systole  and  the  blood  column  is  obstructed  by  tht 
narrowed  aortic  ring.    The  mitral  is  closed  (as  it  should  be). 

The  heart  may  or  may  not  be  enlarged. 

Each  of  these  points  will  now  be  described  more  in  detail. 

(1)  The    Murmur. 

(a)  The  maximum  intensity  of  the  murmur,  as  has  already  been 
said,  is  usually  in  the  second  right  intercostal  space  near  the  ster- 
num or  a  little  above  that  point  near  the  sterno-clavicular  articula- 
tion, but  it  is  by  no  means  uncommon  to  find  it  lower  down,  i.e., 

1  Against  all  reason  I  have  twice  seen  at  autopsy  an  aortic  stenosis  despif- 
the  fact  that  the  "aortic  second  sound  "  had  been  loud  in  life. 


VALVULAR  LESIONS. 


241 


in  the  third,  fourth,  or  fifth  right  interspace,  and  occasionally  it  is 
best  heard  to  the  left  of  the  sternum  in  the  second  or  third  inter- 
costal space.  (&)  The  time  of  the  murmur  is  late  systolic  ;  that  is, 
it  follows  the  apex  impulse  at  an  appreciable  interval,  contrasting 
in  this  respect  with  the  systolic  murmur  usually  to  be  heard  in 
mitral  regurgitation.  (c)  The  murmur  is  usually  widely  transmit- 
ted, often  being  audible  over  the  whole  chest  and  occasionally  over 
the  skull  and  the  arterial  trunks  of  the  extremities  (see  Fig.  140;. 
It  is  usually  heard  less  well  over  that  portion  of  the  precordia  oc- 
cupied by  the  right  ventricle,  while,  on  the  other  hand,  it  is  rela- 
tively loud  in  the  region  of  the  apex  impulse,  whither  it  is  trans- 
mitted through  the  left  ventricle.  The  same  line  of  transmission 


Maximum  intensity 
of  systolic  mur- 
mur and  thrill. 


FIG.  140.— Aortic  Stenosis.    The  murmur  is  audible  over  the  shaded  area  and  sometimes  ovej 

the  whole  chest. 

was  mentioned  above  as  characteristic  of  the  murmur  of  aortic  re- 
gurgitation  in  many  cases.  The  murmur  is  also  to  be  heard  ovei 
the  carotids  and  subclavians,  and  can  often  be  traced  over  the  tho- 
racic aorta  along  the  spine  and  down  the  arms. 

Until  compensation  fails  the  murmur  is  apt  to  be  a  very  loud 
one,  especially  in  the  recumbent   position;    it  is  occasionally  au- 
dible at  some  distance  from  the  chest,  and  is  often  rough  and 
vibrating,  sometimes  musical  or  croaking.     Its  length  is  unusuallv 
16 


242  PHYSICAL  DIAGNOSIS. 

great,  extending  throughout  the  whole  of  systole,  but  to  this  rule 
there  are  occasional  exceptions.  The  first  sound  in  the  aortic  re- 
gion is  altogether  obliterated,  as  a  rule,  and  the  second  sound  is 
usually  either  absent  or  very  feeble.1 

(2)  The  Pulse. 

Owing  to  the  opposition  encountered  by  the  left  ventricle  in 
its  attempt  to  force  blood  into  the  aorta,  its  contraction  is  apt  to 
be  prolonged ;  hence  the  pulse  wave  rises  gradually  and  late,  and  falls 
away  slowly.  This  is  shown  very  well  in  sphygmographic  tracings 
(see  Fig.  141).  But  further,  the  blood  thrown  into  the  aorta  by  the 
left  ventricle  is  prevented,  by  the  narrowing  of  the  aortic  valves, 
from  striking  upon  and  expanding  the  arteries  with  its  ordinary 
force ;  hence  the  pulse  wave  is  not  only  slow  to  rise  but  small  in 


FIG.  141.—  Sphygmographic  Tracing  of  the  Pulse  In  Uncomplicated  Aortic  Stenosis.    Compare 
with  the  normal  pulse  wave  and  with  that  of  aortic  regurgitation  (page  174). 

height,  contrasting  strongly  with  the  powerful  apex  beat  ("pulsus 
parvus  ") .  Again,  the  delay  in  the  emptying  of  the  left  ventricle, 
brought  about  by  the  obstruction  at  the  aortic  valves,  renders  the 
contractions  of  the  heart  relatively  infrequent,  and  hence  the  pulse 
is  infrequent  (pulsus  rarus)  as  well  as  small  and  slow  to  rise.  The 
"pulsus  rarus,  parvtis,  tardus "  is,  therefore,  a  most  constant  and 
important  point  in  diagnosis,  but  unfortunately  it  is  to  be  felt 
in  perfection  only  in  the  very  rare  cases  in  which  aortic  stenosis 
occurs  uncomplicated.  When  stenosis  is  combined  with  regurgita- 
tion, as  is  almost  always  the  case,  the  above-described  qualities  of 
the  pulse  are  usually  modified  as  a  result  of  the  regurgitation. 

1  "Occasionally,  as  noted  by  W.  H.  Dickinson,  there  is  a  musical  murmur 
of  great  intensity  in  the  region  of  the  apex,  probably  due  to  a  slight  regurgi- 
tation at  high  pressure  through  the  mitral  valve." — OSLER. 


VALVULAR  LESIONS.  243 

But  I  have  in  two  cases  observed  a  well  marked  "  Corrigan  "  pulse 
in  life  and  been  confronted  post  mortem  with  a  narrowed,  rigid  aortic 
valve ! 

A  less  characteristic,  but  decidedly  frequent,  variation  in  the 
pulse  wave  of  aortic  stenosis  is  the  anacrotic  curve.  The  slow, 
long  pulse  with  a  long  plateau  at  the  summit  is  seen  also  in  some 
cases  of  mitral  stenosis  and  renal  disease,  and  is  not  peculiar  to 
aortic  stenosis,  but  taken  in  connection  with  the  other  signs  of  the 
disease  it  has  great  value  in  diagnosis. 

(3)  The  Thrill. 

In  the  majority  of  cases  an  intense  purring  vibration  may  be 
felt  if  the  hand  is  laid  over  the  upper  portion  of  the  sternum,  espe- 
cially over  the  second  right  intercostal  space.  This  thrill  is  con- 
tinued into  the  carotids,  can  occasionally  be  felt  at  the  apex,  and 
rarely  over  a  considerable  area  of  the  chest.  It  is  a  very  important 
aid  in  the  diagnosis  of  aortic  stenosis,  but  is  by  no  means  pathog- 
nornonic,  since  aneurism  may  produce  a  precisely  similar  vibration 
of  the  chest  wall. 

The  heart  is  slightly  enlarged  to  the  left  and  downward  as  a 
rule,  but  the  apex  impulse  is  unusually  indistinct,  "  a  well-defined 
and  deliberate  push  of  no  great  violence "  (Broadbent).  Corre- 
sponding to  the  protracted  sustained  systole  the  first  sound  at  the 
apex  is  dull  and  long,  but  not  very  loud. 

Differential  Diagnosis. 

A  systolic  murmur  heard  loudest  in  the  second  right  intercostal 
space  is  by  no  means  peculiar  to  aortic  stenosis,  but  may  be  due  to 
any  of  the  following  conditions : 

(a)  Roughening,  stiffness,  fenestration,  or  slight  congenital  mal- 
formation of  the  aortic  valves. 

(b)  Roughening  or  diffuse  dilatation  of  the  arch  of  the  aorta. 

(c)  Aneurism  of  the  aorta  or  innominate  artery. 

(d)  Functional  murmurs. 

(e)  Pulmonary  stenosis. 
(/)   Open  ductus  arteriosus. 
(#)  Mitral  regurgitation. 


244  PHYSICAL  DIAGNOSIS. 

(a  and  b)  The  great  majority  of  such  systolic  murmurs  at  the 
base  of  the  heart,  first  appearing  after  middle  life,  are  due  to  the 
causes  mentioned  above  under  a,  b,  and  c.  In  such  cases  it  is  usu- 
ally combined  with  accentuation  and  ringing  quality  of  the  aortic 
second  sound  owing  to  the  arterio -sclerosis  and  high  arterial  tension 
associated  with  the  changes  which  produce  the  murmur.  This 
accentuation  of  the  aortic  second  sound  enables  us,  except  in  extraor- 
dinarily rare  cases,  to  exclude  aortic  stenosis,  in  which  the  intensity 
of  the  aortic  second  sound  is  almost  always  much  reduced. 

Diffuse  dilatation  of  the  aorta,  such  as  often  accompanies  aortic 
regurgitation,  is  a  frequent  cause  of  a  systolic  murmur  loudest  in 
the  second  right  interspace.  This  may  be  recognized  in  certain 
cases  by  the  characteristic  area  of  dulness  on  percussion  and  by  its 
association  with  aortic  regurgitation  of  long  standing  (see  Fig.  134). 

Eoughening  of  the  intima  of  the  aorta  (endaortitis)  is  always  to 
be  suspected  in  elderly  patients  with  calcified  and  tortuous  periph- 
eral arteries,  and  such  a  condition  of  the  aorta  doubtless  favors  the 
occurrence  of  a  murmur,  especially  when  accompanied  by  a  slight 
degree  of  dilatation.  The  absence  of  a  thrill  and  a  long,  slow 
pulse  with  a  low  maximum  serves  to  distinguish  such  murmurs 
from  those  of  aortic  stenosis. 

(c)  Aneurism  of  the  ascending  arch  of  the  aorta  or  of  the  in- 
nominate artery  may  give  rise  to  every  sign  of  aortic  stenosis  except 
the  characteristic  pulse  and  the  diminution  of  the  aortic  second 
sound.  In  aneurism  we  may  have  a  well-marked  tactile  thrill  and 
a  loud  systolic  murmur  transmitted  into  the  neck,  but  there  is 
usually  some  abnormal  pulsation  to  be  felt,  an  a-ray  shadow  to  be 
seen,  and  often  some  difference  in  the  pulses  or  in  the  pupils,  as  well 
as  a  history  of  pain  and  symptoms  of  pressure  upon  the  trachea 
and  bronchi  or  recurrent  laryngeal  nerve.  In  aneurism  the  aortic 
second  sound  is  usually  loud  and  accompanied  by  a  shock,  and  the 
pulse  shows  none  of  the  characteristics  of  aortic  stenosis. 

(</)  Functional  murmurs,  sometimes  known  as  "haemic,"  are 
occasionally  best  heard  in  the  aortic  area  instead  of  in  their  usual 
situation  (second  left  intercostal  space).  They  occur  especially  in 
young,  anaemic  persons,  are  not  accompanied  by  any  cardiac  en- 


VALVULAR  LESIONS.  245 

largement,  by  any  palpable  thrill,  any  diminution  in  the  aortic 
second  sound,  or  any  distinctive  abnormalities  in  the  pulse. 

(e)  Pulmonary  stenosis,  a  rare  lesion,  is  manifested  by  a  sys- 
tolic murmur  and  by  a  thrill  whose  maximum  intensity  is  usually 
on  the  left  side  of  the  sternum.  In  the  rare  cases  in  which  this 
murmur  is  best  heard  in  the  aortic  area  it  may  be  distinguished 
from  the  murmur  of  aortic  stenosis  by  the  fact  that  it  is  not  trans- 
mitted into  the  vessels  of  the  neck,  has  no  effect  upon  the  aortic 
second  sound,  and  is  not  accompanied  by  the  characteristic  changes 
in  the  pulse. 

(/")  The  murmur  due  to  persistence  of  the  ductus  arteriosus 
may  last  through  systole  and  into  diastole ;  it  may  be  accompanied 
by  a  thrill,  but  does  not  affect  the  aortic  second  sound  nor  the 
pulse. 

(g)  The  systolic  murmur  of  aortic  stenosis  may  be  heard  loudly  at 
the  apex,  and  hence  the  lesion  may  be  mistaken  for  mitral  regur- 
gitation.  But  the  maximum  intensity  of  the  murmur  of  aortic 
stenosis  is  almost  invariably  in  the  aortic  area,  and  its  association 
with  a  thrill  and  a  long,  slow  pulse  should  enable  us  easily -to  dif- 
ferentiate the  two  lesions. 

By  the  foregoing  differentiae  aortic  stenosis  may  be-distinguished 
from  the  other  conditions  which  resemble  it,  provided  it  occurs 
uncopyplicated,  but  unfortunately  this  is  very  rare.  As  a  rule,  it 
occurs  in  connection  with  aortic  regurgitation,  and  its  characteristic 
signs  are  therefore  obscured  or  greatly  modified  by  the  signs  of  the 
latter  disease.  We  may  suspect  stenosis :  (a)  In  all  young  (rheu- 
matic) patients  with  long-standing  aortic;  regurgitation.1  (U)  In 
older  (arterio-sclerotic)  patients  who  show,  besides  the  signs  of  aor- 
tic regurgitation,  palpable  thrill  in  the  aortic  area  transmitted  into 
the  great  vessels,  a  modification  of  the  Corrigau  pulse  in  the  direc- 
tion of  the  "jntlsus  tardus,  rarus,  parvus,"  and  less  visible  arterial 
pulsation  than  is  to  be  expected  in  pure  aortic  regurgitation. 

Occasionally  one  can  watch  the  development  of  an  aortic  steno- 
sis out  of  what  was  formerly  a  pure  regurgitant  lesion,  the  stenosis 
gradually  modifying  the  characteristics  of  the  previous  condition. 

1  Because  post-mortem  experience  shows  that  in  cases  of  this  type  steno- 
sis and  insufficiencjr  are  usually  combined. 


246  PHYSICAL  DIAGNOSIS. 

One  must  be  careful,  however,  to  exclude  a  relative  mitral  insuffi- 
ciency which,  as  has  been  already  mentioned  above,  is  very  apt  to 
supervene  in  cases  of  aortic  disease,  owing  to  dilatation  of  the  mi- 
tral orifice,  and  which  may  modify  the  characteristic  signs  of  aortic 
regurgitation  very  much  as  aortic  stenosis  does. 

» 
TKICUSPID   KEGUKGITATION. 

Endocarditis  affecting  the  tricuspid  valve  is  rare  in  post-foetal 
life ;  in  the  foetus  it  is  not  so  uncommon.  In  cases  of  ulcerative 
or  malignant  endocarditis  occuring  in  adult  life,  the  tricuspid  valve 
is  occasionally  involved,  but  the  majority  of  cases  of  tricuspid  dis- 
ease occur  as  a  result  of  disease  of  the  mitral  valve  and  in  the  follow- 
ing manner :  Hypertrophy  of  the  right  ventricle  occurs  as  a  result 
of  the  mitral  disease,  is  followed  in  time  by  dilatation,  and  with 
this  dilatation  comes  a  stretching  of  the  ring  of  insertion  of  the 
tricuspid  valve,  and  hence  a  regurgitation  through  that  valve.  Tri- 
cuspid regurgitation,  then,  occurs  in  the  latest  stages  of  almost 
every  case  of  mitral  disease  and  sometimes  during  the  severer  at- 
tacks of  failing  compensation. 

Out  of  405  autopsies  at  Guy's  Hospital  in  which  evidence  of 
tricuspid  regurgitation  was  found,  271,  or  two-thirds,  resulted  from 
mitral  disease,  68  from  myocardial  degeneration,  55  from  pulmonary 
disease  (bronchitis,  emphysema,  cirrhosis  of  the  lung) .  Very  few  of 
these  cases  had  been  diagnosed  during  life,  and  in  all  of  them  the 
valve  was  itself  healthy  but  insufficient  to  close  the  dilated  qrifice. 

Gibson  and  some  other  writers  believe  that  temporary  tricuspid 
regurgitation  is  the  commonest  of  all  valve  lesions,  and  results  from 
weakening  of  the  right  ventricle  in  connection  with  states  of  anse- 
mia,  gastric  atony,  fever,  and  many  other  conditions.  It  is  very 
difficult  to  prove  or  disprove  such  an  assertion. 

Tricuspid  regurgitation  is  often  referred  to  as  serving  like  the 
opening  of  a  "  safety  valve  "  to  relieve  a  temporary  pulmonary  en- 
gorgement. This  "  safety- valve  "  action,  however,  may  be  most 
disastrous  in  its  consequences  to  the  organism  as  a  whole,  despite 
the  temporary  relief  which  it  affords  to  the  overfilled  lungs.  The 
engorgement  is  simply  transferred  to  the  liver  and  thence  to  the 


VALVULAR  LESIONS.  247 

abdominal  organs  and  the  lower  extremities,  so  that  as  a  rule  the 
advent  of  tricuspid  regurgitation  is  recognized  not  as  a  relief  but 
as  a  serious  and  probably  fatal  disaster. 

Physical  Signs. 

(1)  A  systolic  murmur  is  heard  loudest  at  or  near  the  fifth  left 
costal  cartilage. 

(2)  Systolic  venous  pulsation  in  the  jugulars  and  in  the  liver. 

(3)  Engorgement  of  the  right  auricle  producing  an  area  of  dul- 
ness  beyond  the  right  sternal  margin. 

(4)  Intense  cyanosis. 

I 

(1)  The  Murmur. — The  maximum  intensity  of  the  systolic  mur- 
mur of  tricuspid  regurgitation  is  usually  near  the  junction  of  the  fifth 
or  sixth  left  costal  cartilages  with  the  sternum.     Leube  finds  the 
murmur  a  rib  higher  up,  but  it  is  generally  agreed  that  the  tricuspid 
area  is  a  large  one,  so  that  the  murmur  may  be  heard  anywhere 
over  the  lower  part  of  the  sternum  or  even  to  the  right  of  it.     On  the 
other  hand,  there  are  some  tricuspid  murmurs  which  are  best  heard 
at  a  point  midway  between  the  apex  impulse  and  the  ensif  orm  carti- 
lage.    The  murmur  is  not  widely  transmitted  and  is  usually  inaudi- 
ble in  the  back ;  at  the  end  of  expiration  its  intensity  is  increased. 

In  some  cases  we  have  no  evidence  of  tricuspid  regurgitation 
other  4;han  the  murmur  just  described,  but — 

(2)  Of  more  importance  in  diagnosis  is  the  presence  of  a  sys- 
tolic pulsation  in  the  external  jugular  veins  and  of  the  liver,  which 
unfortunately  is  not  always  present,  but  which  when  present  is 
pathognomonic.     I  have  already  explained  (see  p.  88)  the  distinc- 
tion between  true  systolic  jugular  pulsation,  which  is  practically 
pathognomonic  of  tricuspid  regurgitation,  and  simple  presystolic 
undulation  or  distention  of  the  same  veins,  which  has  no  necessary 
relation  to  this  disease.     The  decisive  test  is  the  effort  permanently 
to  empty  the  vein  by  stroking  it  upward  from  below.     If  it  in- 
stantly refills  from  below  and  continues  to  pulsate,  tricuspid  regur- 
gitation is  almost  certainly  present.     If,  on  the  other  hand,  it  does 
not  refill  from  below,  the  cause  must  be  sought  elsewhere. 


248 


PHYSICAL   DIAGNOSIS. 


Pulsation  in  the  liver  must  be  distinguished  from  the  "jogging  " 
motion  which  may  be  transmitted  to  it  from  the  abdominal  aorta  or 
from  the  right  ventricle.  To  eliminate  these  transmitted  impulses 
one  must  be  able  to  grasp  the  liver  bknanually,  one  hand  in  front 
and  one  resting  on  the  lower  ribs  behind,  and  to  feel  it  distinctly  ex- 
pand with  every  systole,  or  else  to  take  its  edge  in  the  hand  and 
to  feel  it  enlarge  in  one's  grasp  with  every  beat  of  the  heart. 


Dilated  right 
auricle. 


Systolic  munnur.    -— " 


Enlarged  and  DU  • 
sating  liver. 


FIG.  142.— Tricuspid  Regurgitation.    The  murmur  is  heard  best  over  the  shaded  area. 

Pressure  upon  the  liver  often  causes  increased  distention  and  pulsa- 
tion of  the  external  jugulars  if  tricuspid  re  gurgitation  is  present. 

(3)  Enlargement  of  the  heart,  both  to  the  right  and  to  the  left, 
as  well  as  downward,  can  usually  be  demonstrated.     In  rare  cases 
a  dilatation  of  the  right  auricle  may  be  suggested  by  a  percussion 
outline  such  as  that  shown  in  Fig.  142. 

The  pulmonic  second  sound  is  usually  not  accented.  The  im- 
portance of  this  in  differential  diagnosis  will  be  mentioned  pres- 
ently. If  a  progressive  diminution  in  the  intensity  of  the  sound 
occurs  under  observation,  the  prognosis  is  very  grave. 

(4)  Cyanosis  is  usually  very  great,  and  dyspnoea  and  general 
dropsy  often  make  the  patient's  condition  a  desperate  one. 


VALVULAR  LESIONS.  249 

Differential  Diagnosis. 

The  statistics  of  the  cases  autopsied  at  the  Massachusetts  Gen- 
eral Hospital  show  that  tricuspid  regurgitation  is  less  often  recog- 
nized during  life  than  any  other  valvular  lesion.  The  diagnosis 
was  made  ante  mortem  on  only  five  out  of  twenty -nine  cases. 
This  is  due  to  the  following  facts : 

(a)  Tricuspid  regurgitation  may  be  present  and  yet  give  rise  to 
no  physical  signs  which  can  be  recognized  during  life. 

(6)  Tricuspid  regurgitation  occurs  most  frequently  in  connec- 
tion with  mitral  regurgitation;  hence  its  signs  are  frequently 
masked  by  those  of  the  latter  lesion.  It  is,  therefore,  a  matter  of 
great  importance  as  well  as  of  great  difficulty  to  distinguish  tricus- 
pid regurgitation  from 

(1)  Mitral  Regurgitation. 

The  difficulties  are  obvious.  The  murmur  of  mitral  regurgita- 
tion has  its  maximum  intensity  not  more  than  an  inch  or  two  from 
the  point  at  which  the  tricuspid  murmur  is  best  heard.  Both  are 
systolic  in  time.  They  are,  therefore,  to  be  distinguished  only — 

(a)  In  case  we  can  demonstrate  that  there  are  two  areas  in 
which  a  systolic  murmur  is  heard  with  relatively  great  intensity, 
with  an  intervening  space  over  which  the  murmur  is  less  clearly  to 
be  heard  (see  Fig  143).  • 

(&)  Occasionally  the  two  systolic  murmurs  are  of  different  pitch 
or  of  different  quality,  and  may  be  thus  distinguished. 

(c)  Tricuspid  murmurs  are  not  transmitted  into  the  left  axilla 
and  are  rarely  audible  in  the  back,  and  this  fact  is  of  value  in  case  we 
have  to  distinguish  between  uncomplicated  tricuspid  regurgitation 
and  uncomplicated  mitral  regurgitation.  Unfortunately  these  le- 
sions are  very  apt  to  occur  simultaneously,  so  that  in  practice  our 
efforts  are  generally  directed  toward  distinguishing  between  a  pure 
mitral  regurgitation  and  one  complicated  by  tricuspid  regurgitation. 

(cT)  In  cases  of  doubt  the  phenomena  of  venous  pulsation  in  the 
jugulars  and  in  the  liver  are  decisive  if  present,  but  their  absence 
iroves  nothing. 


250 


PHYSICAL  DIAGNOSIS. 


(e)  Accentuation  of  the  pulmonic  second  sound  is  almost  inva- 
riably present  in  uncomplicated  mitral  disease  and  is  apt  to  disap- 
pear in  case  the  tricuspid  begins  to  leak,  since  engorgement  of  the 
lungs  is  thereby  for  the  time  relieved,  but  in  many  cases  the  pul- 
monic second  sound  remains  most  unaccountably  strong  even  when 
the  tricuspid  is  obviously  leaking. 

(2)  From  "  functional "  systolic  murmurs  tricuspid  insufficiency 
may  generally  be  distinguished  by  the  fact  that  its  murmur  is  best 


FIG.  143.— Two  Systolic  Murmurs  (Mitral  and  Tricuspid)  with  a  "  Vanishing  Point "  between. 

heard  in  the  neighborhood  of  the  ensiform  cartilage,  and  not  in  the 
second  right  intercostal  space  where  most  functional  murmurs  have 
their  seat  of  maximum  intensity.  Functional  murmurs  are  unac- 
companied by  venous  pulsation,  cardiac  dilatation,  or  cyanosis. 

(3)  Occasionally  a  pericardial  friction  rub  simulates  the  mur- 
mur of  tricuspid  insufficiency,  but,  as  a  rule,  pericardial  friction  is 
much  more  irregular  in  the  time  of  its  occurrence  and  is  not  regu- 
larly synchronous  with  any  definite  portion  of  the  cardiac  cycle. 

TRICUSPID  STENOSIS. 

One  of  the  rarest  of  valve  lesions  is  narrowing  of  the  tricuspid 
valve.  No  case  has  come  under  my  observation,  and  in  1898,  Her- 


VALVULAR  LESIONS.  251 

rick  was  able  to  collect  but  154  cases  from  the  world's  literature. 
Out  of  these  154  cases,  138,  or  90  per  cent,  were  combined  with 
mitral  stenosis,  and  only  12  times  has  tricuspid  stenosis  been  known 
to  occur  alone.1  These  observations  account  for  the  fact  that  tri- 
cuspid stenosis  has  hardly  ever  been  recognized  during  life,  since  the 
murmur  to  which  it  'gives  rise  is  identical  in  time  and  quality  and 
nearly  identical  in  position  with  that  of  mitral  stenosis.  Narrow- 
ing of  the  tricuspid  valve  is  to  be  diagnosed,  therefore,  only  by  the 
recognition  of  a  presystolic  murmur  best  heard  in  the  tricuspid  area 
and  distinguished  either  by  its  pitch,  quality,  or  position  frOm  the 
other  presystolic  murmur  due  to  the  mitral  stenosis  which  is  almost 
certain  to  accompany  it. 

The  heart  is  usually  enlarged,  especially  in  its  transverse  direc- 
tion, but  the  enlargement  is  just  such  as  mitral  stenosis  produces, 
and  does  not  aid  our  diagnosis  at  all. 

The  diagnosis  is  still  further  complicated  in  many  cases  by  the 
presence  of  an  aortic  stenosis  in  addition  to  a  similar  lesion  at  the 
tricuspid  and  mitral  valves,  so  that  it  seems  likely  that  in  the  future 
as  in  the  past  the  lesion  will  be  discovered  first  at  autopsy. 

PULMONARY  REGUBGITATION. 

Organic  disease  of  the  pulmonary  valve  is  excessively  rare  in 
post-foetal  life,  but  may  occur  as  part  of  an  acute  ulcerative  or 
septic  endocarditis.  A  temporary  functional  regurgitation  through 
the  pulmonary  valve  may  be  brought  about  by  any  cause  producing 
very  high  pressure  in  the  pulmonary  artery.  I  have  known  two 
medical  students  with  perfectly  healthy  hearts  who  were  able,  by 
prolonged  holding  of  the  breath,  to  produce  a  short,  high-pitched 
diastolic  murmur  best  heard  in  the  second  and  third  left  intercostal 
spaces  and  ceasing  as  soon  as  the  breath  was  let  out.  Of  the  occur- 
rence of  a  murmur  similarly  produced  under  pathological  condi- 
tions, especially  in  mitral  stenosis,  much  has  been  written  by 
Graham  Steell. 

1  Out  of  87  cases  collected,  from  the  post-mortem  records  of  Guy's  Hos- 
pital, 85,  or  97  per  cent,  were  associated  with  still  more  extensive  mitral 
stenosis. 


252  PHYSICAL  DIAGNOSIS. 

From  the  diastolic  murmur  of  aortic  regurgitation  we  may  dis- 
tinguish the  diastolic  murmur  of  pulmonary  incompetency  by  the 
fact  that  the  latter  is  best  heard  over  the  pulmonary  valve,  is  never 
transmitted  to  the  apex  of  the  heart  nor  to  the  great  vessels,  and 
is  never  associated  with  a  Corrigaii  pulse  nor  with  capillary  pulsa- 
tion.1 The  right  ventricle  is  hypertrophied,  the  pulmonic  second 
sound  is  sharply  accented  and  followed  immediately  by  the  murmur. 
Evidences  of  septic  embolism  of  the  lungs  are  frequently  present 
and  assist  us  in  diagnosis.  The  regurgitation  which  may  take 
place  through  the  rigid  cone  of  congenital  pulmonary  stenosis  is 
not  recognizable  during  life. 

PULMONARY    STENOSIS. 

Among  the  rare  congenital  lesions  of  the  heart  valves  this  is 
probably  the  commonest.  The  heart,  and  particularly  the  right 
ventricle,  is  usually  much  enlarged.  There  is  a  history  of  cyanosis 
and  dyspnoea  since  birth.  Pulmonary  tuberculosis  complicates  from 
one-fourth  ta  one-third  of  all  cases.  A  systolic  thrill  is  usually  to 
be  felt  in  the  second  left  intercostal  space,  and  a  loud  systolic  mur- 
mur is  heard  in  the  same  area.  The  pulmonic  second  sound  is  weak. 

The  region  in  which  this  murmur  is  best  heard  has  been  happily 
termed  the  "  region  of  romance  "  on  account  of  the  multiplicity  of 
mysterious  murmurs  which  have  been  heard  there.  The  systolic 
murmur  of  pulmonary  stenosis,  must  be  distinguished  from 

(a)  Functional  murmurs  due  to  anaemia  and  debility  or  to  severe 
muscular  exertion,  and  possibly  associated  with  a  dilatation  of  the 
conus  arteriosus. 

(b)  Uncovering  of  the  conus  arteriosus  through  lack  of  expan- 
sion of  the  lung. 

(c)  Aortic  stenosis. 

(d)  Mitral  regurgitation. 

(e)  Aneurism. 

(/)  Roughening  of  the  intima  of  the  aortic  arch. 

1  By  registering  the  variations  of  pressure  in  the  tracheal  column  of  ail 
Gerhardt  has  shown  graphically  that  a  systolic  pulsation  of  the  pulmonary  cap- 
illaries may  occur  in  pulmonary  regurgitation.  With  the  stethoscope  a  sys- 
tolic whiff  may  be  heard  all  over  the  lungs. 


VALVULAR  LESIONS.  253 

(a  and  5)  Functional  murmurs,  and  those  produced  in  the  conus 
arteriosus,  are  rarely  if  ever  accompanied  by  a  thrill,  are  rarely  so 
loud  as  the  murmur  of  pulmonary  stenosis,  and  are  not  associated 
with  dyspnoea,  cyanosis,  and  enlargement  of  the  right  ventricle. 

(o)  The  murmur  of  aortic  stenosis  is  usually  upon  the  right  side 
of  the  sternum  and  is  transmitted  to  the  neck,  whereas  the  murmur 
of  pulmonary  stenosis  is  never  so  transmitted  and  is  not  associated 
with  characteristic  changes  hi  the  pulse  (see  above,  p.  242). 

(W)  The  murmur  of  mitral  regurgitation  is  occasionally  loudest 
in  the  region  of  the  pulmonary  valve,  but  differs  from  the  murmur 
of  pulmonary  stenosis  hi  being,  as  a  rule,  transmitted  to  the  back 
and  axilla  and  associated  with  an  accentuation  of  the  pulmonary 
second  sound. 

(e)  Aneurism  may  present  a  systolic  murmur  and  thrill  similar 
to  those  found  in  pulmonary  stenosis,  but  may  usually  be  distin- 
guished from  the  latter  by  the  presence  of  the  positive  signs  of  aneur- 
ism, viz. — pulsation,  and  dulness  in  the  region  of  the  murmur,  and 
signs  of  pressure  on  the  trachea  or  on  other  structures  in  the  medi- 
astinum. 

(/)  Roughening  of  the  aortic  arch  occurs  after  middle  life, 
while  pulmonary  stenosis  is  usually  congenital.  The  murmur  due 
to  roughening  may  be  transmitted  into  the  carotids ;  that  of  pul- 
monary stenosis  never.  Enlargement  of  the  right  ventricle  is  char- 
acteristic of  pulmonary  stenosis,  but  not  of  aortic  roughening. 

\ 
COMBINED   VALVULAR   LESIONS. 

It  is  essential  that  the  student  should  understand  from  the  first 
that  the  number  of  murmurs  audible  in  the  precordia  is  no  gauge 
for  the  number  of  valve  lesions.  We  may  have  four  distinct  mur- 
murs, yet  every  valve  sound  except  one.  This  is  often  the  case  in 
aortic  regurgitation  —  systolic  and  diastolic  murmurs  at  the  base  of 
the  heart,  systolic  and  presystolic  at  the  apex,  yet  no  valve  in- 
jured except  the  aortic.  In  such  a  case  the  systolic  aortic  murmur 
is  due  to  roughening  of  the  aortic  valve.  The  systolic  apex  mur- 
mur results  from  relative  mitral  leakage  (with  a  sound  valve).  The 
presystolic  apex  murmur  is  of  the  "  Flint "  type.  Hence  in  this 


254  PHYSICAL  DIAGNOSIS. 

case  the  diastolic  murmur  alone  of  the  four  audible  murmurs  is  due 
to  a  valvular  lesion. 

It  is  a  good  rule  not  to  multiply  causes  unnecessarily,  and  to 
explain  as  many  signs  as  possible  under  a  single  hypothesis  In 
the  above  example  the  mitral  leak  might  be  due  to  an  old  endocar- 
ditis, and  there  might  be  mitral  stenosis  and  aortic  stenosis  as  well, 
but  since  we  can  explain  all  the  signs  as  results — direct  and  indirect 
— of  one  lesion  (aortic  regurgitation)  it  is  better  to  do  so,  and  post- 
mortem experience  shows  that  our  diagnosis  is  more  likely  to  be 
right  when  it  is  made  according  to  this  principle. 

The  most  frequent  combinations  are : 

(1)  Mitral  regurgitation  with  mitral  stenosis. 

(2)  Aortic  regurgitation  with  mitral  regurgitation  (with  or  with- 
out stenosis). 

(3)  Aortic  regurgitation  with  aortic  stenosis,  with  or  without 
mitral  disease. 

(1)  Double  Mitral  Disease. 

(a)  It  very  frequently  happens  that  the  mitral  valve  is  found 
to  be  both  narrowed  and  incompetent  at  autopsy  when  only  one  of 
these  lesions  had  been  diagnosed  during  life.  In  fact  mitral  steno- 

1st 


il 

I       hi,                   2nd  .il  I 

lilllllini    I Jl 


FIG.  144.— Mitral  Stenosis  and  Regurgltation,  showing  relation  of  murmur  to  first  heart  sound. 

sis  is  almost  never  found  at  autopsy  wit>  uit  an  associated  regurgi- 
tation, so  that  it  is  fairly  safe  to  assume,  whenever  one  makes  the 
diagnosis  of  mitral  stenosis,  that  mitral  regurgitation  is  present  as 
well,  whether  it  is  possible  to  hear  any  regurgitant  murmur  or  not 
(see  Fig.  144). 

(£)  On  the  other  hand,  with  a  double  mitral  lesion  one  may 
have  only  the  regurgitant  murmur  at  the  mitral  valve  and  nothing 
to  suggest  stenosis  unless  it  be  a  surprising  sharpness  of  the  first 
mitral  sound.  In  chronic  cases  the  changeableness  of  the  murmurs 
both  in  type  and  position  is  extraordinary.  One  often  finds  at  one 


VALVULAR  LESIONS. 


255 


vdsit  evidences  of  mitral  stenosis  and  at  another  evidences  of  mitral 
regurgitation  alone.  Either  murmur  may  disappear  altogether  foi 
a  time  and  reappear  subsequently.  This  is  peculiarly  true  of  the  pre- 
systolic  murmur,  which  is  notoriously  one  of  the  most  fleeting  and 
uncertain  of  all  physical  signs. 

As  a  rule  the  same  inflammatory  change*  which  produce  mitral 
regurgitation  in  early  life  result  as  they  extend  in  narrowing  the 
mitral  valve,  so  that  the  signs  of  stenosis  come  to  predominate  in 
later  years.  Coincidently  with  this  narrowing  of  the  diseased  valve 
a  certain  amount  of  improvement  in  the  patient's  symptoms  may 
take  place,  and  Rosenbach  regards  the  advent  of  stenosis  in  such  a 
case  as  an  attempt  at  a  regenerative  or  compensatory  change.  In 
many  cases,  however,  no  such  amelioration  of  the  symptoms  follows. 

(2)  Aortic  Regurgitation  with  Mitral  Disease. 

The  signs  of  mitral  disease  occurring  in  combination  with 
aortic  regurgitation  do  not  differ  essentially  from  those  of  pure 


Systolic  murmur 
over  dilated-*' 
aortic  arch. 


Maximum  intensity 
and  diastolic  mur- 
m  u  r,  conducted 
up  and  down. 


•Systolic  murmur. 


FIG.  145.— Aortic  and  Mitral  Regurgitation.    The  shaded  areas  are  those  in  which  the  murmurs 

are  loudest. 

mitral  disease  except  that  the  enlargement  of  the  heart  is  apt  to 
be  more  general  and  correspond  less  exclusively  to  the  right  ven- 
tricle (see  Figs.  145  and  146).  The  manifestations  of  the  aortic  le- 


256  PHYSICAL  DIAGNOSIS. 

sion,  on  the  other  hand,  are  considerably  modified  by  their  associa- 
tion with  the  mitral  disease.  The  Corrigan  pulse  is  distinctly  less 
sharp  at  the  summit  and  rises  and  falls  less  abruptly.  Capillary 

1st  1st 


2nd 


I 


2nd 


I  i 


FIG.  146.— Showing  Relation  of  Murmurs  to  Heart  Sound  in  Regurgitation  at  the  Aortic  ano 

Mitral  Valves. 

pulse  is  less  likely  to  be  present,  and  the  throbbing  of  the  peripheral 
arteries  is  less  often  visible. 

(3)  Aortic  Regurgitation  with  Aortic  Stenosis. 

If  the  aortic  valves  are  narrowed  as  well  as  incompetent,  we 
find  very  much  the  same  modification  of  the  physical  signs  charac- 
teristic of  aortic  regurgitation  as  is  produced  by  the  advent  of  a 
mitral  lesion ;  that  is  to  say,  the  throbbing  in  the  peripheral  ar- 
teries is  less  violent,  the  characteristics  of  the  radial  pulse  are  less 
marked,  and  the  capillary  pulsation  is  not  always  to  be  obtained 
at  all.  Indeed,  this  blunting  of  all  the  typical  manifestations  of 
aortic  regurgitation  may  give  us  material  aid  in  the  diagnosis  of 
aortic  stenosis,  provided  always  that  the  mitral  valve  is  still  per- 
forming its  function. l 

(4)  The  association  of  mitral  disease  with  tricuspid  insufficiency 
has  been  already  described  on  -p.  218. 

1  Some  astonishing  exceptions  to  this  rule  have  been  mentioned  on  pages 
240  and  243. 


CHAPTER   XI. 

PAKIETAL  DISEASE.— CAEDIAC  NEUROSES.— CONGEN1 
TAL  MALFORMATIONS  OF  THE  HEART. 

PARIETAL  DISEASE  OF  THE  HEART. 
Acute  Myocarditis. 

THE  myocardium  is  seriously,  though  not  incurably,  affected  in 
all  continued  fevers,  owing  less  to  the  fever  itself  than  to  the  tox- 
aemia associated  with  it.  "Cloudy  swelling,"  or  granular  degener- 
ation of  the  muscle  fibres,  is  produced  by  relatively  mild  infections, 
while  a  general  septicaemia  due  to  pyogenic  organisms  may  produce 
extensive  fatty  degeneration  of  the  heart  within  a  few  days. 

The  physical  signs  are  those  of  cardiac  weakness.  The  most 
significant  change  is  in  the  quality  of  the  first  sound  at  the  apex 
of  the  heart,  which  becomes  gradually  shorter  until  its  quality  is 
like  that  of  the  second  sounds,  while  in  some  cases  its  feebleness 
makes  the  second  sounds  seem  accented  by  comparison.  Soft  blow- 
ing7 systolic  murmurs  may  develop  at  the  pulmonary  orifice,  less 
often  at  the  apex  or  over  the  aortic  valve. 

The  apex  impulse  becomes  progressively  feebler  and  more  like 
a  tap  than  a  push.  Irregularity  and  increasing  rapidity  are  omi- 
nous signs  which  may  be  appreciated  in  the  radial  pulse,  but  still 
better  by  auscultation  of  the  heart  itself.  In  most  of  the  acute  in- 
fections evidence  of  dilatation  of  the  weakened  cardiac  chambers  is 
rarely  to  be  obtained  during  life  (although  at  autopsy  it  is  not  in- 
frequently found),1  but  in  acute  articular  rheumatism  an  acute  dila- 
tation of  the  heart  appears  to  be  a  frequent  complication,  independ- 

1  Henchen's  recent  monograph  on  this  subject,  "Ueber  die  acute  Herzdila- 
tation  bei  acuten  Infectionskrankheiten,"  Jena,  1899,  does  not  seem  to  me 
Convincing. 

11 


258  PHYSICAL  DIAGNOSIS. 

ent  of  the  existence  of  any  valvular  disease.  Attention  has  been 
especially  called  to  this  point  by  Lees  and  Boy n ton  (British  Med. 
Jour.,  July  2,  1898)  and  by  S.  West. 

IXFLUENZA  is  also  complicated  not  infrequently  by  acute  cardiac 
dilatation. 

Weakened  Heart  ("  Chronic  Myocarditis  " ). 

Fatty  or  fibroid  changes  in  the  heart  wall  occuring  in  chronic 
disease  may  result  from  coronary  sclerosis  and  imperfect  nutrition 
of  the  myocardium,  but  in  many  cases  no  lesions  are  found  post 
mortem  in  the  heart,  the  heart  weakening  as  a  result  of  long-con- 
tinued overwork  against  an  increased  arterial  resistance  (nephritis, 
arterio-sclerosis) . 

Whether  definite  myocardial  changes  are  present  or  not,  the 
signs  are  the  same. 

Physical  Signs  of  Weakened  Heart. 

For  the  sure  recognition  of  changes  in  the  myocardium  our 
present  methods  of  physical  examination  are  always  unsatisfactory 
and  often  wholly  inadequate.  Extensive  degenerations  of  the 
heart  wall  are  not  infrequently  found  at  autopsy  when  there  has 
been  no  reason  to  suspect  them  during  life.  On  the  other  hand, 
the  autopsy  often  fails  to  substantiate  a  diagnosis  of  degeneration 
of  the  heart  muscle,  although  all  the  physical  signs  traditionally 
associated  with  this  condition  were  present  during  life.1  To  a  con- 
siderable extent,  therefore,  our  diagnosis  of  myocarditis  must  de- 
pend upon  the  history  and  symptoms  of  the  case ;  physical  exami- 
nation can  sometimes  supplement  these,  sometimes  not.  Symptoms 
of  cardiac  weakness  developing  in  a  man  past  middle  life,  especially 
in  a  patient  who  shows  evidences  of  arterio-sclerosis  or  high  ar- 
terial tension,  or  who  has  suffered  from  the  effects  of  alcohol  and 
syphilis,  suggest  parietal  disease  of  the  heart,  fatty  or  fibroid. 
The  probability  is  increased  if  there  have  been  attacks  of  angina 
pectoris,  Cheyne-Stokes  breathing,  or  of  syncope. 

Inspection  and  palpation  may  reveal  nothing  abnormal,  or  there 

1  A  well-known  Boston  pathologist  recently  told  me  that  he  had  never 
known  a  case  of  myocarditis  correctly  diagnosed  during  life. 


PARIETAL  DISEASE.  259 

may  be  an  unusually  diffuse,  slapping  cardiac  impulse  associated 
perhaps  with  a  displacement  of  the  apex  beat  to  the  left  and  down- 
ward. Marked  irregularity  of  the  heart  beat,  both  in  force  and  in 
rhythm,  is  sometimes  demonstrable  by  these  methods,  and  an  in- 
crease in  the  area  of  cardiac  dulness  may  be  demonstrable  in  case 
dilatation  has  followed  the  weakening  of  the  heart  wall.  Ausculta- 
tion may  reveal  nothing  abnormal  except  that  the  aortic  second 
sound  is  unusually  sharp ;  in  some  cases  feeble  and  irregular  heart 
sounds  are  heard,  although  the  first  sound  at  the  apex  is  not  infre- 
quently sharp.  Blood  pressure  is  often  much  increased.  The 
sounds  may  be  reduplicated  and  "  gallop  rhythm  "  is  not  infrequent. 
If  the  mitral  sphincter  is  dilated,  or  the  papillary  muscles  are  weak- 
ened, as  not  infrequently  happens,  we  may  have  evidences  of  mitral 
regurgitation,  a  systolic  murmur  at  the  apex  heard  in  the  left  axilla 
and  back  with  accentuation  of  the  pulmonic  second  sound. 

Summary. 

1.  The  history  and  symptoms  of  the  case  or  the  condition  of 
other  organs  are  often  of  move  diagnostic  value  than  is  the  physical 
examination  of  the  heart  itself,  which  may  show  nothing  abnormal. 

2.  Among  the  rather  unreliable  physical  signs,  those  most  often 
mentioned  are : 

(a)   Weakness  and  irregularity  of  the  heart  sounds. 
(6)   Increased  blood  pressure. 

(c)  A  diffuse  slapping  cardiac  impulse. 

(d)  Reduplication    of    some    of    the    cardiac    sounds    (gallop 
rhythm). 

(e)  Evidences  of  cardiac  dilatation. 

(/)  Murmurs — especially  the  murmur  of  mitral  insufficiency 
which  often  occurs  as  a  result  of  dilatation  of  the  valve  orifices  and 
weakening  of  the  cardiac  muscle. 

A 
Differential  Diagnosis. 

We  have  to  distinguish  the  weakened  heart  from — 
(a)   Uncomplicated  valvular  lesions. 
(/;)   Cardiac  neuroses. 


260  PHYSICAL  DIAGNOSIS. 

(a)  It  has  been  already  pointed  out  that   valvular  lesions  do 
not  necessarily  give  rise  to  any  murmurs  when  compensation  has 
failed.      Under  such  circumstances  one  hears  only  irregular  and  weak 
heart  sounds,  as  in  myocarditis.      The  history  of  a  long-standing 
valvular  trouble,  a  knowledge  of  the  previous  history  of  the  case, 
the  age,  method  of  onset,  and  the  high  blood  pressure  may  assist  us 
in  the  diagnosis.     Cases  of  weakened  heart  are  less  often  associated 
with  extensive  dropsy  than  are  cases  of  valvular  disease  whose  com- 
pensation has  been  ruptured. 

(b)  Weakness  and  irregularity  of  the  cardiac  sounds,  when  due 
to  nervous  affection  of  the  heart  and  unassociated  with  parietal  or 
valvular  changes,  is  usually  less  marked  after  slight  exertion.     The 
heart  "  rises  to  the  occasion  "  if  the  weakness  is  a  functional  one. 
On  the  other  hand,  if  any  serious  weakening  is  present,  the  signs 
and  symptoms  are  much  aggravated  by  any  exertion. 

In  some  cases  of  myocarditis  the  pulse  is  excessively  slow  and 
shows  no  signs  of  weakness.  This  point  will  be  referred  to  again 
in  the  chapter  on  Bradycardia. 

Fatty  Overgrowth. 

An  abnormally  large  accumulation  of  fat  about  the  heart  may 
be  suspected  if,  in  a  very  -obese  person,  signs  of  cardiac  embarrass- 
ment (dyspnoea,  palpitation)  are  present,  and  if  on  examination  we 
find  that  the  heart  sounds  are  feeble  and  distant  but  preserve  the 
normal  difference  from  each  other.  When  the  heart  wall  is  seri- 
ously weakened  (as  in  the  later  weeks  of  typhoid),  the  heart  sounds 
become  more  alike  owing  to  the  shortening  of  the  first  sound. 

In  fatty  overgrowth  this  is  not  the  case. 

The  diagnosis,  however,  cannot  be  positively  made.  We  sus- 
pect it  under  the  conditions  above  described,  but  no  greater  cer- 
tainty can  be  attained. 

Fatty  Degeneration. 

There  are  no  physical  signs  by  which  fatty  degeneration  of  the 
heart  can  be  distinguished  from  other  pathological  changes  which 
result  in  weakening  the  heart  walls.  An  extensive  degree  of  fatty 


CARDIAC  NEUROSES.  261 

degeneration  is  often  seen  post  mortem  in  cases  of  pernicious  anaemia, 
although  the  heart  sounds  have  been  clear,  regular,  and  in  all  re- 
spects normal  during  life.  The  little  we  know  of  the  physical 
signs  common  to  fatty  degeneration  and  to  other  forms  of  parietal 
disease  of  the  heart- has  been  included  in  the  section  on  Weakened 
Heart  (see  p.  257). 

CARDIAC  NEUROSES. 
Tachycardia  (Rapid  Heart). 

Simple  quickening  of  the  pulse  rate,  or  tachycardia,  which  may 
pass  altogether  unnoticed  by  the  patient  himself,  is  to  be  distin- 
guished from  palpitation,  in  which  the  heart  beats,  whether  rapid 
or  not,  force  themselves  upon  the  patient's  attention. 

The  pulse  rate  may  vary  a  great  deal  in  health.  A  classmate 
of  mine  at  the  Harvard  Medical  School  had  a  pulse  rarely  slower 
than  100,  yet  his  heart  and  other  organs  were  entirely  sound.  Such 
cases  are  not  very  uncommon,  especially  in  women.  Temporarily 
the  pulse  rate  may  be  greatly  increased,  not  only  by  exercise  and 
emotion,  but  by  the  influence  of  fever,  of  gastric  disturbances,  or  of 
the  menopause.  Such  a  tachycardia  is  not  always  of  brief  duration 
The  effects  of  a  great  mental  shock  may  produce  an  acceleration  of 
the  pulse  which  persists  for  days  or  even  weeks  after  the  shock. 

Among  organic  diseases  associated  with  weakening  of  the  pulse 
the  commonest  are  those  of  the  heart  itself.  Next  to  them,  exoph- 
thalmic goitre,  tumors  or  hemorrhage  in  the  medulla,  and  obscure 
diseases  of  the  female  organs  of  generation,  are  the  most  frequent 
causes  of  tachycardia. 

The  only  form  of  tachycardia  which  is  worthy  to  be  considered 
as  a  more  or  less  independent  malady  is 

Paroxysmal  Tachycardia. 

As  indicated  in  the  name,  the  attacks  of  this  disease  are  apt  to 
begin  and  to  cease  suddenly.  They  may  last  a  few  hours  or  several 
days.  The  pulse  becomes  frightfully  rapid,  often  200  per  minute  or 
more.  Bristowe  records  a  case  with  a  pulse  of  308  per  minute 


262  PHYSICAL  DIAGNOSIS. 

In  the  radial  artery  the  pulse  beat  may  be  impalpable.  The  heart 
sounds  are  regular  and  clear,  but  the  diastolic  pause  is  shortened  and 
the  first  sound  becomes  short  and  "  valvular,"  resembling  the  sec- 
ond ("tic-toe  heart"}.  The  paroxysm  may  be  associated  with 
aphasia  and  abnormal  sensations  in  the  left  arm.  Occasionally  the 
heart  becomes  dilated,  and  oedema  of  the  lungs,  albuminuria,  and 
other  manifestations  of  stasis  appear.  Usually,  however,  the  par- 
oxysm has  no  serious  results.  It  can  be  distinguished  from  the 
tachycardia  of  cardiac  dilatation  by  the  fact  that  the  heart  remains 
perfectly  regular.  This  same  fact  also  assists  us  in  excluding  the 
cardiac  neuroses  due  to  tobacco,  tea,  and  other  poisons.  From  the 
tachycardia  of  Graves'  disease  the  affection  now  in  consideration 
differs  by  its  paroxysmal  and  intermittent  character. 

Bradycardia  (Slow  Heart). 

In  many  healthy  adults  the  heart  seldom  beats  over  50  times  a 
minute. 

I.  Among  the  causes  which  may  produce  for  a  short   time  an 
abnormally  slow  heart -beat  are : 

(a)  Exhaustion;  for  example,  after  fevers,  after  parturition,  or 
severe  muscular  exertion. 

(b)  Toxaemia  ;  for  example,  jaundice,  uraemia,  auto-intoxications 
in  dyspepsia. 

(c)  In  certain  hysterical  and  melancholic  states  and  in  neurotic 
children,  the  pulse  may  be  exceedingly  slow      Pain  has  also  a  ten- 
dency to  retard  the  pulse. 

(d)  An  increase  of  intracranial  pressure,  as  in  meningitis,  cere- 
bral hemorrhage,  depressed  fracture  of  the  skull.     Possibly  in  this 
category  belong  the  cases  of  bradycardia  sometimes  seen  in  epilep- 
tiform  or  during  syncopal  attacks.     Bradycardia  from  any  one  of 
these  causes  is  apt  to  be  of  comparatively  short  duration. 

II.  Stokes- Adams'   disease   (due  to  a  lesion  of  the  bundle  of 
His)  refers  especially  to  a  paroxysmal  bradycardia  with  syncope, 
yet  the  pulse  may  remain  below  40  for  months,  though  strong  and 
regular,  and  the  patient  may  be  free  from  symptoms  of  any  kind. 
The  rate  of  the  heart-beat  cannot  be  estimated  by  counting  the  ra- 


CARDIAC  NEUROSES.  263 

dial  pulse.  Careful  study  of  the  jugular  motions,  especially  with  a 
polygraph,  usually  shows  that  some  auricular  beats  do  not  reach 
the  ventricle  (heart  block)  so  that  there  are  2  or  3  beats  in  the 
jugular  for  every  1  in  the  radial. 

Arrhythmia. 

1 .  Physiological  Arrhythmia.  — Arrhythmia,  or  irregularity  in  the 
force  or  rhythm  of  the  heart-beat,  is  to  a  certain  extent  physiologi- 
cal. The  heart  normally  beats  a  little  faster  and  a  little  more  strongly 
during  inspiration  than  during  expiration.  Any  psychical  disturb- 
ance or  muscular  exertion  may  produce  irregularity  as  well  as  a 
quickening  of  the  heart -beat.  Rarely  the  pulse  may  be  irregular 
throughout  life  in  perfectly  healthy  persons.  This  irregularity  is 
usually  of  rhythm  ajone;  every  second  or  third  beat  may  be  regu- 
larly omitted  without  the  individual  knowing  anything  about  it  or 
feeling  any  disagreeable  symptoms  connected  with  it.  More  rarely 
the  heart's  beats  may  be  permanently  irregular  in  force  as  well  as 
rhythm  despite  the  absence  of  any  discoverable  disease. 

In  children  the  pulse  is  especially  apt  to  be  irregular,  and  dur- 
ing sleep  some  children  show  that  modification  of  rhythm  known 
as  the  "paradoxical  pulse,"  which  consists  in  a  quickening  of  the 
pulse  with  diminution  in  volume  during  inspiration. 

(2)  If  we  leave  on  one  side  diseases  of  the  heart  itself,  patho- 
7ogical  arrhythmia  is  most  frequently  seen  in  persons  who  have  used 
vbacco  or  tea  to  excess,  or  in  dyspepsia.  In  these  conditions  it  is 
often  combined  with  palpitation  and  becomes  thereby  very  distress- 
ing to  the  patient.  In  connection  with  cardiac  disease  the  follow- 
ing types  of  arrhythmia  may  be  distinguished : 

(a)  Paradoxical  Pulse. — Any  cause  which  leads  to  weakening 
of  the  heart's  action  may  occasionally  be  associated  with  paradoxical 
pulse.  Fibrous  pericarditis  has  been  supposed  to  be  frequently 
associated  with  this  type  of  arrhythmia,  but  if  so  it  is  by  no  means 
its  only  cause. 

(6)  The  bigeminal  pulse  is  seen  most  frequently  in  cases  of  un- 
compensated  heart  disease  (particularly  mitral  stenosis)  after  the 
administration  of  digitalis.  Every  other  beat  is  weak  or  abortive 


264  PHYSICAL  DIAGNOSTS. 

and  is  succeeded  by  an  unusually  long  pause.  Sometimes  everj 
third  beat  is  of  the  abortive  type,  or  an  unusually  long  interval 
may  divide  the  heart-beats  into  groups  of  three  ("tripeminal 
pulse"). 

(c)  Embryocardia,  or  the  "tic-tac  heart,"  represents  a  shorten- 
ing of  the  diastolic  pause  and  of  the  first  sound  of  the  heart  so  that 
it  resembles  the  second  sound,  as  in  the  foetal  heart.  Any  case  of 
uncompensated  heart  disease,  whether  valvular  or  parietal,  may  be 
associated  with  this  disturbance  of  rhythm. 

(cT)  The  gallop  rhythm. 

Owing  to  a  reduplication  of  one  of  the  heart  sounds  (usually 
the  second),  we  may  have  three  sounds  instead  of  two  with  each 
beat  of  the  heart,  the  sounds  possessing  a  rhythm  which  reminds  us 
of  the  hoof -beats  of  a  galloping  horse  (see  p.  181) .  This  rhythm  is 
heard  especially  in  the  failing  heart  of  interstitial  nephritis  or  cor- 
onary sclerosis. 

(e)  Delirium  cordis  is  a  term  used  to  express  any  great  irregu- 
larity and  rapidity  of  the  heart-beats  which  cannot  be  reduced  to 
a  single  type  or  rhythm.  It  is  seen  in  the  gravest  stages  of  uncom- 
pensated heart  disease. 

Palpitation. 

Best  defined  as  an  "  irregular  or  forcible  heart  action  perceptible 
to  the  individual"  The  essential  point  is  that  the  individual 
becomes  conscious  of  each  beat  of  his  heart,  whether  or  no  the  heart 
action  is  in  any  way  abnormal. 

(a)  In  irritable  conditions  of  the  nervous  system,  such  as  occur 
at  puberty,  at  climacteric,  or  in  neurasthenic  persons,  palpitation 
may  be  very  distressing.     Temporary  disturbances,  such  as  fright, 
may  produce  a  similar  and  more  or  less  lasting  effect. 

(b)  The  effect  of  high  altitudes,  or  of  even  a  moderate,  eleva- 
tion (1,500  feet)  is  sufficient  to  produce  in  many  healthy  persons  a 
quickening  and  strengthening  of  the  heart's  action,  so  that  sleep 
may  be  prevented.     After   a   few  nights   this   condition   usually 
passes  off,  provided  the  heart  is  sound. 

(c)  Abuse  of  tobacco  and  tea  have  a  similar  effect. 


CONGENITAL  HEART  DISEASE.  265 

Auscultation  of  a  palpitating  heart  shows  nothing  more  than 
unusually  loud  and  ringing  heart  sounds,  but  since  palpitation  is 
often  associated  with  arrhythmia  of  one  or  another  type  we  must  be 
careful  to  exclude  the  palpitation  symptomatic  of  acute  dilatation 
of  the  heart,  such  as  may  occur  in  debilitated  persons  after  violent 
or  unusual  exertion.  In  this  condition  the  area  of  cardiac  dulness 
is  increased  and  dyspnoea  upon  slight  exertion  becomes  marked.  It 
goes  without  saying  that  in  almost  any  case  of  organic  disease  of 
the  heart  palpitation  may  be  a  very  marked  and  distressing  synip-" 
torn. 

CONGENITAL  HEAKT   DISEASE. 

From  the  time  of  birth  it- is  noticed  in  some  cases  that  the  child 
is  markedly  cyanosed,  hence  the  term  "blue  baby."  Dyspnoea  is 
often,  though  not  always,  present,  and  may  interfere  with- sucking. 
The  cyanosis,  if  present,  is  practically  sufficient  in  itself  for  the 
diagnosis. 

Among  congenital  diseases  of  the  heart  the  commonest  and  the 
most  important  (because  it  is  less  likely  than  any  of  the  others  to 
prove  immediately  fatal)  is : 

1.  Pulmonary  Stenosis. 

This  lesion  is  usually  the  result  of  foetal  endocarditis,  and  is 
often  associated  with  malformations  and  defects,  such  as  patency 
of  the  foramen  ovale  and  persistence  of  the  ductus  arteriosus.  The 
physical  signs  of  pulmonary  stenosis  are : 

(a)  A  palpable  systolic  thrill  most  distinct  in  the  pulmonary 
area. 

(b)  A  loud  systolic  murmur  (often  rough  or  musical)  heard  best 
in  the  same  region,  but  transmitted  to  all  parts  of  the  chest. 

(c)  A  weak  or  absent  pulmonic  second  sound. 

(rf)  An  increased  area  of  cardiac  dulness  corresponding  to  the 
right  ventricle. 

Unlike  most  other  varieties  of  congenital  heart  disease,  pulmo- 
nary stenosis  is  compatible  with  life  for  many  years,  and  "blue 
babies  "  with  this  lesion  may  grow  up  and  enjoy  good  health,  al- 


266  PHYSICAL  DIAGNOSIS. 

though  usually  subject  to  pulmonary  disorders  (pneumonia  or  tu- 
berculosis) For  a  discussion  of  the  differential  diagnosis  of  this 
lesion,  see  above,  p.  252. 

2.  Defects  in  the  Ventricular  Septum. 

The  loud  systolic  murmur  produced  by  the  rush  of  blood  through 
an  opening  between  the  ventricles  is  heard,  as  a  rule,  over  the  whole 
precordia.  Its  point  of  maximum  intensity  differs  in  different 
cases,  but  is  hardly  ever  near  the  apex  of  the  heart.  The  most  im- 
portant diagnostic  point  is  the  absence  of  a  palpable  thrill.  With 
almost  every  other  form  of  congenital  heart  disease  in  which  a  loud 
murmur  is  audible,  there  is  a  thrill  as  well  Hypertrophy  of  both 
ventricles  may  be  present,  but  is  seldom  marked  in  uncomplicated 
cases. 

(Patency  of  the  foramen  ovale,  if  unassociated  with  other  de- 
fects, does  not  usually  produce  any  murmur  or  other  signs  by  which 
it  can  be  recognized  during  life,  and  causes  no  symptoms  of  any 
kind.) 

3.  Persistence  of  the  Ductus  Arteriosus. 

The  most  characteristic  sign  is  a  loud,  vibratory  systolic  mur- 
mur with  its  intensity  at  the  base  of  the  heart  and  unassociated  with 
hypertrophy  of  either  ventricle.  If  complicated  with  stenosis  at  or 
close  above  the  pulmonary  valves,  persistence  of  the  ductus  arte- 
riosus  cannot  be  diagnosed,  as  the  murmur  produced  by  it  cannot 
with  certainty  be  distinguished  from  that  of  the  pulmonary  ste- 
nosis, and  the  presence  of  hypertrophy  of  the  right  ventricle  de- 
prives us  of  the  one  relatively  characteristic  mark  of  a  patent  arte- 
rial duct. 

Gibson  considers  that  a  murmur  persisting  through  systole  and 
into  diastole  is  diagnostic  of  an  open  arterial  duct,  but  this  sup- 
position is  not  borne  out  in  all  cases  by  post-mortem  evidence. 

The  signs  produced  by  the  other  varieties  of  congenital  heart 
disease,  such  as  aortic  stenosis  and  tricuspid  or  mitral  lesions,  do 
not  differ  materially  from  those  characterizing  those  lesions  in 


CONGENITAL  HEART  DISEASE.  267 

adults.  Excluding  these,  we  may  summarize  the  signs  of  the  othei 
lesions  as  follows : 

(a)  Practically  all  cases  of  congenital  heart  disease,  which  pro- 
duce any  physical  signs  beyond  cyanosis  and  dyspnoea,  manifest 
themselves  by  a  loud  systolic  murmur  heard  all  over  the  precordia 
and  often  throughout  the  chest.  Its  maximum  intensity  is  usually 
at  or  near  the  base  of  the  heart. 

(&)  If  there  is  no  thrill  and  no  hypertrophy,  the  lesion  is  prob- 
ably a  defect  in  the  ventricular  septum. 

(c)  If  there  is  a  thrill  but  no  hypertrophy,  the  lesion  is  probably 
a  patent  ductus  arteriosus. 

(d)  If  there  is  a  thrill  and  hypertrophy  of  the  right  ventricle, 
the  lesion  is  probably  pulmonic  stenosis,  especially  if  the  pulmonic 
second  sound  is  feeble. 


CHAPTER   XII. 

DISEASES  OF  THE  PERICARDIUM. 

I.  PERICARDITIS. 

THREE  forms  are  recognized  clinically : 

(1)  Plastic,  dry,  or  fibrinous  pericarditis. 

(2)  Pericarditis  with  effusion  (serous  or  purulent). 

(3)  Pericardial  adhesions  or  adherent  pericardium 
Fibrinous  pericarditis  may  be  fully  developed  without  giving 

rise  to  any  physical  signs  that  can  be  appreciated  during  life.  In 
several  cases  of  pneumonia  in  which  I  suspected  that  pericarditis 
might  be  present,  I  have  listened  most  carefully  for  evidences  of 
the  disease  and  been  unable  to  discover  any ;  yet  at  autopsy  it  was 
found  fully  developed — the  typical  shaggy  heart.  We  have  every 
reason  to  believe,  therefore,  that  pericarditis  is  frequently  present 
but  unrecognized,  especially  in  pneumonia  and  in  the  rheumatic  at- 
tacks of  children.  On  the  other  hand,  it  may  give  rise  to  very 
marked  signs  which  are  the  result  of — 

(a)  The  rubbing  of  the  roughened  pericardial  surfaces  against 
one  another  when  set  in  motion  by  the  cardiac  contractions. 

(b)  The  presence  of  fluid  in  the  pericardial  sac. 

(c)  The  interference  with  cardiac  contractions  brought  about  by 
obliteration  of  the  pericardial  sac  together  with  the  results  of  ad- 
hesions between  the  pericardium  and  the  surrounding  structures. 

(1)  DRY  OR  FIBRINOUS  PERICARDITIS. 

The  diagnosis  rests  upon  a  single  physical  sign — "pericardial 
friction  " — which  is  usually  to  be  appreciated  by  auscultation  alone, 
but  may  occasionally  be  felt  as  well.  Characteristic  pericardial 
friction  is  a  rough,  irregular,  grating  or  shuffling  sound  which  oc- 


DISEASES   OF  THE  PERICARDIUM.  269 

curs  irregularly  and  interruptedly  during  the  larger  part  of  each 
cardiac  cycle.  It  is  almost  never  accurately  synchronous  either 
with  systole  or  diastole,  but  overlaps  the  cardiac  sounds,  and  en- 
croaches upon  the  pauses  in  the  heart  cycle.  It  is  seldom  exactly 
the  same  in  any  two  successive  cardiac  cycles  and  differs  thereby 
from  sounds  produced  within  the  heart  itself.  Pericardial  friction 
seems  very  near  to  the  ear  and  may  often  be  increased  by  pressure 


L  J L  _  „  Pericardial  friction. 


FIG.  147.— Showing  Most  Frequent  Site  of  Audible  Pericardial  Friction. 

with  the  stethoscope ;  it  is  not  materially  influenced  by  the  respi- 
ratory movements. 

It  is  best  heard  in  the  majority  of  cases  in  the  position  shown 
in  Fig.  147 ;  that  is,  over  that  portion  of  the  heart  which  lies  near- 
est to  the  chest  wall  and  is  not  covered  by  the  margins  of  the  lungs ; 
but  not  infrequently  it  may  be  heard  at  the  base  of  the  heart  or 
over  the  whole  precordial  region.  The  sounds  are  fainter  if  the 
patient  lies  on  the  right  side,  and  sometimes  intensified  if,  while 
sitting  or  standing,  he  leans  forward  and  toward  the  left,  so  as  to 
bring  the  heart  into  closer  apposition  with  the  chest  wall. 

Pericardial  friction  sounds  often  change  rapidly  from  hour 
to  hour,  and  may  disappear  and  reappear  in  the  course  of  a 
day. 


270  PHYSICAL  DIAGNOSIS. 

In  rare  cases  the  friction  may  occur  only  during  systole  or  only 
during  diastole.  In  such  cases  the  diagnosis  between  pericardial 
and  intracardial  sounds  may  be  very  difficult. 

DIFFERENTIAL  DIAGNOSIS. 

(a)  Pleuro- Pericardial  Friction. 

Fibrinous  inflammation  affecting  that  part  of  the  pleura  which 
overlaps  the  heart  may  give  rise  to  sounds  altogether  indistinguish- 
able from,  those  of  true  pericardial  friction  when  the  inflamed  pleu- 
ral  surfaces  are  made  to  grate  against  one  another  by  the  move- 
ments of  the  heart.  Such  sounds  are  sometimes  increased  in 
intensity  during  forced  respiration  and  disappear  at  the  end  of 
expiration,  while  true  pericardial  friction  is  usually  best  heard  if 
the  breath  is  held  at  the  end  of  expiration.  If  a  friction  sound 
heard  in  the  pericardial  region  ceases  altogether  when  the  breath 
is  held,  we  may  be  sure  that  it  is  produced  in  the  pleura  and  not 
in  the  pericardium,  but  in  many  cases  the  diagnosis  cannot  be  made 
correctly. 

(£)  Intracardiac  Murmurs. 

From  murmurs  due  to  valvular  disease  of  the  heart,  pericardial 
friction  can  usually  be  distinguished  by  the  fact  that  the  sounds  to 
which  it  gives  rise  do  not  accurately  correspond  either  with  systole 
or  diastole,  and  do  not  occupy  constantly  any  one  portion  of  either 
of  these  periods.  Cardiac  murmurs  are  more  regular,  seem,  less 
superficial,  and  vary  less  with  position  and  from  hour  to  hour. 
Pressure  with  the  stethoscope  does  not  increase  so  considerably  the 
intensity  of  intracardiac  murmurs.  When  endocarditis  and  peri- 
carditis occur  simultaneously,  it  may  be  very  difficult  to  distinguish 
the  two  sets  of  sounds  thus  produced.  The  pericardial  friction  is 
usually  recognized  with  comparatively  little  difficulty,  but  it  is 
hard  to  make  sure  whether  in  addition  we  hear  endocardial  mur- 
murs as  well. 


DISEASES   OF  THE  PERICARDIUM. 


271 


(2)  PERICAKDIAL  EFFUSION. 

Following  the  fibriiious  exudation,  which,  roughens  the  pericar- 
dia! surface  and  produces  the  friction  sounds  just  described,  serum 
may  accumulate  in  the  pericardial  sac.  Its  quantity  may  exceed 
but  slightly  the  amount  of  fluid  normally  present  in  the  pericar- 


FIG.  148.— Pericardial  Effusion,  Cardio-hepatic  Angle  obtuse.    (From  v.  Zierassen's  Atlas.) 

dium,  or  may  be  so  great  as  to  embarrass  the  cardiac  movements 
and  finally  to  arrest  them  altogether.  In  chronic  (usually  tubercu- 
lous) cases,  the  pericardium  may  become  stretched  so  as  to  hold  a 
quart  or  more  without  seriously  interfering  with  the  heart's  action, 
while  a  much  smaller  quantity,  if  effused  so  rapidly  that  the  peri- 
cardium has  no  time  to  accommodate  itself  by  stretching,  will  prove 
rapidly  fatal. 


272  PHYSICAL  DIAGNOSIS. 

Hydropericardium  denotes  a  dropsy  of  the  pericardium  occur- 
ring by  transudation  as  part  of  a  general  dropsy  in  cases  of  renal 
disease  or  cardial  weakness.  The  physical  signs  to  which  it  gives 
rise  do  not  differ  from  those  of  an  inflammatory  effusion,  and,  ac- 
cordingly, all  that  is  said  of  the  latter  in  the  following  section  may 
be  taken  as  equally  an  account  of  the  signs  of  hydropericardium. 

Haemopericardium,  or  blood  in  the  pericardial  sac,  due  to  stabs 
or  to  ruptures  of  the  heart,  is  usually  so  rapidly  fatal  that  no 
physical  signs  are  recognizable. 

Physical  Signs  of  Pericardial  Effusion. 

In  most  cases  a  pericardial  friction  rub  has  been  observed  prior 
to  the  time  of  the  fluid  accumulation.  The  presence  of  fluid  in  the 
pericardial  sac  is  shown  chiefly  in  three  ways : 

(1)  By  percussion,  which  demonstrates  an  area  of  dulness  more 
or  less  characteristic  (see  below). 

(2)  By  auscultation,  which  may  reveal  an  unexpected  feebleness 
in  the  heart  sounds  when  compared  with  the  power  shown  in  the 
radial  pulse. 

(3)  By  the  signs  and  symptoms  of  pressure  exerted  by  the  peri- 
cardial effusion  upon  surrounding  structures. 

Bulging  of  the  precordia  is  occasionally  to  be  seen  in  children ; 
in  adults  we  sometimes  observe  a  flattening  of  the  interspaces  just 
to  the  right  of  the  sternum  between  the  third  and  sixth  ribs. 

(1)  The  Area,  of  Percussion  Dulness. — The  extent  of  the  dull 
area  depends  not  only  on  the  size  of  the  effusion  and  the  position  of 
the  patient,  but  also  on  the  amount  of  "give"  in  the  pericardium 
and  in  the  lungs  as  well  as  on  the  size  of  the  lingula  pulmonalis. 
Allowing  for  these  uncertain  factors,  we  may  say:  (a)  One  of  the 
most  characteristic  points  is  the  unusual '  extension  of  the  percus- 
sion dulness  a  considerable  distance  to  the  left  of  the  maximum 
cardiac  impulse,  (b)  Next  to  this,  it  is  important  to  notice  a  change 
in  the  angle  made  by  the  junction  of  the  horizontal  line  covrespond- 

i  In  health  the  cardiac  dulness  extends  about  f  of  an  inch  beyond  the  maxi- 
mum cardiac  impulse,  but  in  pericardial  effusion  the  difference  is  greater. 


DISEASES  OF  THE  PERICARDIUM. 


273 


ing  to  the  upper  limit  of  hepatic  duluess  and  the  nearly  perpendicu- 
lar line  corresponding  to  the  right  border  of  the  heart.  In  health 
this  cardio-hepatic  angle  is  approximately  a  right  angle;  in  pericar- 
dial  effusion  it  is  much  more  obtuse  (see  Fig.  149).  Rotch'  has 
called  attention  to  the  importance  of  dulness  in  the  fifth  right  inter- 
costal space  as  a  sign  of  pericardial  effusion,  bnt  a  similar  dulness 
may  be  produced  by  enlargement  of  the  liver. 

Except  for  the  two  points  mentioned  above  (the  unusual  exten- 
sion of  the  dulness  to  the  left  of  the  cardiac  impulse  and  the  blunting 
of  the  cardio-hepatic  angle),  there  seems  to  me  to  be  nothing  charac- 
teristic about  the  area  of  dulness  produced  by  pericardial  effusion. 


Tympany, 


_4--  •   Dulness, 


-  Cardiac  Impulse. 


Liver  dulness. 


FIG.  149.— Percussion  Dulness  in  Pericardial  Effusion,  with  Tympanitic  Resonance  Under  the 

Left  Clavicle. 

The  "pear-shaped"  or  triangular  area  of  percussion  dulness  men- 
tioned by  many  writers  has  not  been  present  in  cases  which  have 
come  under  my  observation.  In  large  effusions  percussion  reso- 
nance may  be  diminished  in  the  left  back,  and  under  the  left  clav- 
icle the  percussion  note  may  be  tympanitic  from  relaxation  of  the 
lung.  Traube's  semilunar  space  may  be  obliterated,  but  this  occurs 
also  in  pleuritic  effusions. 

In  some  cases  the  area  of  dulness  may  be  modified  by  change  in 
the  patient's  position.     After  marking  out  the  area  of  percussion 
L8 


274  PHYSICAL  DIAGNOSIS. 

dullness  with  the  patient  in  the  upright  position,  let  him  lie  upon 
his  right  side.  The  right  border  of  the  area  of  dulness  will  some- 
times move  considerably  farther  to  the  right.  A  dilated  heart  can 
be  made  to  shift  in  a  similar  way,  but  to  a  lesser  extent.  Compar- 
atively little  change  takes  place  if  the  patient  lies  on  his  left  side, 
and  no  important  information  is  elicited  by  placing  him  flat  on  his 
back  or  by  getting  him  to  lean  forward. 

Unfortunately,  it  is  only  with  moderate-sized  effusions  occur- 
ring in  a  pericardial  sac  free  from  adhesions  to  the  surrounding 
parts  that  this  shifting  can  be  made  out.  Large  effusions  may  not 
shift  appreciably,  and  less  than  150  c.c.  of  fluid  probably  cannot  be 
recognized  by  this  or  by  any  other  method.  But  with  large  effu- 
sions the  lateral  extension  of  the  area  of  dulness  may  be  so  great 
as  to  be  almost  distinctive  in  itself,  i.e.,  from  the  middle  of  the  left 
axilla  nearly  to  the  right  nipple. 

(2)  Feebleness  of  the  heart  sounds  and  of  the  apex  impulse  is  of 
diagnostic  importance  only  when  it  gradually  takes  the  place  of  the 
normal  phenomena  as  one  watches  the  heart  from  day  to  day. 
Under  these  conditions  they  have  some  confirmatory  value  in  the 
diagnosis  of  pericardial  effusion. 

Tubular  breathing  with  increased  voice  sounds  and  tactile  frem- 
itus  can  often  be  heard  near  the  angle  of  the  left  scapula.  This  is 
a  result  of  compression  of  the  lung,  but  is  often  mistaken  for 
pneumonia. 

(3)  Pressure  exerted  by  the  pericardial  exudation  upon  sur- 
rounding structures  may  give   rise   to   dyspnoea,  especially  of  a 
paroxysmal  type,  to  dysphagia,  to  aphonia,  and  to  an  irritating 
cough.     The  "paradoxical  pulse,"  small  and  feeble  during  inspira- 
tion, is  occasionally  to  be  seen,  but  is  by  no  means  peculiar  to  this 
condition  and  has  no  considerable  diagnostic  importance. 

(4)  Inspection  and  palpation  usually  help  us  very  little,  but  two 
points  are  occasionally  demonstrable  by  these  methods : 

(a)  A  smoothing  out  of  the  intercostal  depression  in  the  precor- 
dial  region,  especially  near  the  right  border  of  the  sternum  between 
the  third  and  the  sixth  ribs. 

(&)  A  progressive  diminution  of  the  intensity  of  the  apex  im- 
pulse until  it  may  be  altogether  lost.  If  this  change  occurs  while 


DISEASES  OF  THE  PERICARDIUM  275 

the  patient  is  under  observation,  and  especially  if  the  apex  impulse 
reappears  or  becomes  more  distinct  when  the  patient  lies  on  the 
right  side,  it  is  of  considerable  diagnostic  value.  In  conditions 
other  than  pericardial  effusion,  the  apex  impulse  becomes  less  visible 
in  the  right-sided  decubitus. 

Differential  Diagnosis. 

(1)  Our  chief  difficulty  is  to  distinguish  the  disease  from  hyper- 
trophy and  dilatation  of  the  heart.     In  the  latter,  which  often  com- 
plicates acute  articular  rheumatism  with  or  without  plastic  pericar- 
ditis, the  apex  impulse  is  often  very  indistinct  to  sight  and  touch 
as  in  pericardial  effusion.     But  the  area  of  dulness  is  l^ss  likely  to 
extend  beyond  the  apex  impulse  to  the  left  or  to  modify  the  cardio- 
hepatic  angle,  or  to  shift  when  the  patient  lies  on  the  right  side. 
Pressure  symptoms  are  absent,  and  there  are  no  areas  of  broncho- 
vesicular  breathing  with  tympanitic  resonance  under  the  left  clavicle 
or  in  the  back.     Yet  not  infrequently  these  differentiae  do  not  serve 
us,  and  the  diagnosis  can  be  made  only  by  puncture. 

(2)  I  have  twice  known  cases  of  interlobar  empyema  mistaken 
for  pericardial  effusion.     In  one  case  a  needle  introduced  in  the 
fifth  intercostal  space  below  the  nipple  drew  pus  from  what  turned 
out  later  to  be  a  localized  purulent  pleurisy,  but  the  diagnosis  was 
not  made  until  a  rib  had  been  removed  and  the  region  thoroughly 
explored.      It  is  not  rare  for  pleuritic    effusions    to  gather  first 
in   this  situation,  viz.,  just  outside  the  apex  impulse  in  the  left 
axilla. 

Such  effusions  may  gravitate  very  slowly  to  the  bottom  of  the 
pleural  cavity  or  may  become  encapsulated  and  remain  in  their 
original  and  very  deceptive  position.  In  such  cases  the  signs  of 
compression  of  the  left  lung  are  similar  to  those  produced  by  a 
pericardial  effusion,  and  the  results  of  punctures  may  be  equivocal 
as  in  the  case  just  mentioned.  If  there  is  any  dulness,  even  a  very 
narrow  zone,  in  the  left  axilla  between  the  fifth  and  eighth  ribs, 
though  there  be  none  in  the  back,  the  likelihood  of  empyema  should 
be  suggested. 

As  between  pleuritic  and  pericardial  effusion  the  "presence  of  a 


276  PHYSICAL  DIAGNOSIS. 

good  pulse  and  the  absence  of  marked  dyspnoea  favors  the  former. 
In  the  two  cases  above  referred  to  in  which  inteiiobar  empyema  was 
mistaken  for  pericarditis,  the  general  condition  of  the  patient  struck 
me  at  the  time  as  surprisingly  good  for  pericarditis. 

If  both  pleurisy  and  pericarditis  are  present,  the  area  of  peri- 
cardial  dulness  is  not  characteristic  until  the  pleuritic  fluid  has  been 
drawn  off.  The  persistence  of  dulness  in  the  cardio-hepatic  angle 
and  beyond  the  apex  beat  after  a  left  pleurisy  has  been  emptied  by 
tapping,  and  after  the  heart  has  had  time  to  return  to  its  normal 
position,  should  make  us  suspect  a  pericardial  effusion. 

Despite  the  utmost  care  and  thoroughness  in  physical  examina- 
tion, many  cases  of  pericardial  effusion  go  unrecognized,  especially 
in  infants,  in  elderly  persons,  or  when  the  lung  borders  are  adher- 
ent to  the  pericardium  or  to  the  chest  wall. 

In  the  rheumatic  attacks  of  children,  it  should  be  remembered 
that  pericarditis  is  even  more  common  than  endocarditis. 

Adherent  Pericardium. 

In  the  majority  of  cases  the  diagnosis  cannot  be  made  during 
life,  unless  the  pericardium  is  adherent,  not  only  to  the  heart,  but 
ro  the  walls  of  the  chest  as  well.  When  this  combination  of  peri- 
carditis with  chronic  mediastinitis  is  present,  the  diagnosis  may  be 
suggested  by 

(a)  A  systolic  retraction  of  the  chest  wall  in  the  region  of  the 
apex  impulse,  at  the  base  of  the  left  axilla  and  in  the  region  of  the 
eleventh  and  twelfth  ribs  in  the  left  back  (Broadbent's  sign).     Such 
retraction  is  more  marked  during  a  deep  inspiration.     (It  should 
be  remembered  that  systolic  retraction  of  the  interspaces  in  the 
vicinity  of  the  apex  is  very  commonly  seen  in  cases  of  cardiac  hy- 
pertrophy from,  any  cause,  owing  to  the  negative  pressure  produced 
within  the  chest  by  the  contraction  of  a  powerful  heart.)     A  quick 
rebound  of  the  cardiac  apex  at  the  time  of  diastole  (the  diastolic 
shock)  is  said  to  be  characteristic  of  pericardial  adhesions,  but  is 
often  absent. 

(b)  Collapse  of  the  cervical  veins  during  diastole  has  been  no- 
ticed by  Friedreich,  and  the  paradoxical  pulse,  above  described,  is 


DISEASES  OF  THE  PERICARDIUM.  "All 

said  to  be  more  marked  in  adherent  pericardium  than  in  any  other 
known  condition.  Most  recent  writers,  however,  place  no  reliance 
upon  it. 

(c)  When  the  lungs  are  adherent  to  the  pericardium  or  to  the 
chest  wall,  as  is  not  uncommonly  the  case,  the  absence  of  the  phrenic 
phenomenon  (Litten's  signs)  and  of  any  respiratory  excursion  of 
the  pulmonary  margins  may  be  demonstrated.  Since  pericardial 
adhesions  are  most  often  due  to  tuberculosis,  the  discovery  of  tu- 
berculosis in  the  lung  or  elsewhere  may  be  of  aid  in  diagnosis. 

(d~)  Broadbent  considers  that  the  absence  of  any  shift  in  the 
position  of  the  apex  beat,  with  respiration  or  change  of  patient's 
position,  is  an  important  point  in  favor  of  mediastino-pericarditis. 
In  health  and  in  valvular  or  parietal  disease  of  the  heart,  the  apex 
beat  will  swing  from  one  to  two  inches  to  the  left  when  the  patient 
lies  on  his  left  side,  and  the  descent  of  the  diaphragm  during  full 
inspiration  lowers  the  position  of  the  cardiac  impulse  considerably. 

(e)  The  presence  of  hypertrophy  or  dilatation  affecting  espe- 
cially the  right  side  of  the  heart,  and  not  accounted  for  by  the 
existence  of  any  disease  of  the  cardiac  valves,  of  the  lung,  or  of 
the  kidney,  should  make  us  suspect  pericardial  and  mediastinal 
adhesions.  Such  adhesions  embarrass  especially  the  right  ven- 
tricle, because  it  is  the  right  ventricle  far  more  than  the  left  which 
becomes  attached  to  the  chest  wall.  The  left  ventricle  is  more 
nearly  free. 

(/)  Since  the  space  enclosed  by  the  divergent  costal  cartilage 
just  below  the  ensiforrn  is  but  loosely  associated  with  the  cen- 
tral tendon  of  the  diaphragm,  Broadbent  looks  especially  at  this 
point  for  evidence  of  mediastinal  or  pericardial  adhesions,  the 
effect  of  which  is  to  arrest  completely  the  slight  respiratory  move- 
ments of  this  part  of  the  abdominal  wall. 

(y~)  Adherent  pericardium,  occurring  as  a  part  of  a  widespread 
chain  of  fibrous  processes  involving  the  pleura,  the  mediastinum, 
and  the  peritoneum,  may  give  rise  in  young  persons  to  a  train  of 
symptoms  and  signs  suggesting  cirrhosis  of  the  liver.  Ascites 
collects,  the  liver  is  enlarged,  yet  there  are  no  signs  in  the  heart, 
kidneys,  or  blood  sufficient  to  explain  the  condition.  In  any 
such  case  adherent  pericardium  should  be  considered.  Fig.  150 


278 


PHYSICAL  DIAGNOSIS. 


show  the  appearance  in  cases  of  this  kind  in  which  the  diagnosis 
was  verified  by  autopsy. 


FIG.  150.— Adherent  Pericardium,  Ascites. 


Summary. 

The  diagnosis  of  adherent  pericardium  with  chronic  niediastini 
tis  is  suggested  by 


DISEASES   OF  THE  PERICARDIUM.  279 

(a)  Systolic  retraction  of  the  lower  intercostal  spaces  in  the  left 
axilla  and  in  the  left  back,  followed  by  a  diastolic  rebound. 

(t>)  The  absence  of  any  change  in  the  position  of  the  apex  im- 
pulse with  respiration  or  change  of  position. 

(c)  The  presence  of  hypertrophy  and  dilatation  of  one  or  both 
ventricles  without  obvious  cause. 

(c?)  The  absence  of  any  respiratory  excursion  of  the  lung  bor- 
ders near  the  heart  and  of  the  abdominal  wall  at  the  costal  angle. 

(e)  The  presence  of  signs  like  those  of  hepatic  cirrhosis  in  a 
young  person  and  without  any  obvious  cause. 


CHAPTER   XIII. 

THOKACIC  ANEURISM. 
ANEURISM   OF  THE  THORACIC  AORTA. 

FOR  clinical  purposes  thoracic  aneurisms  may  be  divided  into 
the  diffuse  and  the  saccular.  Saccular  aneurisms  of  the  ascending 
or  descending  portion  of  the  arch  of  the  aorta  are  apt  to  penetrate 
the  chest  wall,  while  aneurism  of  the  transverse  aorta  or  diffuse 
dilatations  of  the  whole  aortic  arch  are  more  likely  to  extend  within 
the  chest  without  eroding  the  thoracic  bones.  Practically  any 
aneurism  which  penetrates  the  thoracic  bones  may  be  inferred  to 
be  saccular,  but  if  no  such  penetration  takes  place,  it  may  be  im- 
possible to  make  out  whether  the  dilatation  is  diffuse  or  circum- 
scribed. I  shall  consider: 

I.  The  signs  of  the  presence  of  aneurism. 

II.  The  evidences  of  its  seat. 

Inspection  and  palpation  give  us  most  of  the  important  informa- 
tion in  the  diagnosis  of  aneurism.  The  patient  should  be  placed  in 
the  position  shown  in  Fig.  151,  so  that  the  light  will  strike  obliquely 
across  the  surface  of  the  chest,  and  the  observer  should  be  so  placed 
that  his  eyes  are  as  nearly  as  possible  at  the  level  at  that  part  of 
the  chest  at  which  he  expects  to  see  pulsation. 

In  the  majority  of  cases  of  aneurism  some  abnormal  pulsation 
may  be  made  out  either  to  the  right  of  the  sternum  in  front  or  in 
Abnormal  tne  region  of  the  left  scapula  behind.  If  the  aneur- 
Pulsation.  ism  is  large,  a  considerable  area  of  the  chest  wall  may 
be  lifted  with  each  beat  of  the  heart ;  with  smaller  growths  the 
pulsating  area  may  be  small  and  sharply  circumscribed.  Not  in- 
frequently an  abnormal  pulsation  at  the  sternal  notch  or  in  the 


THORACIC  ANEURISM. 


281 


neck  may  be  observed.  Other  causes  of  abnormal  pulsations  in 
the  chest,  such  as  dislocation  or  uncovering  of  the  heart,  must  of 
course  be  excluded.  Pulsations  due  to  aneurism  can  sometimes 
be  distinctly  seen  to  occur  later  than  the  apex  impulse  of  the  heart. 

Palpation  controls  the  results  of  inspection,  but  at  times  a  pul- 
sation may  be  seen  better  than  felt ;  at  others  may  be  felt  better 
than  seen.  Binianual  palpation — one  hand  over  the  suspected  area 
in  front  and  one  in  a  corresponding  position  behind  —is  useful. 

If  the  aneurism  involves  the  ascending  portion  of  the  aortic 


FIG.  151.—  Position  When  Looking  for  Slight  Aueurismal  Pulsation. 

arch,  it  is  likely  sooner  or  later  to  erode  the  right  margin  of  the 
sternum  and  the  adjacent  parts  of  the  second  or  third  costal  car- 
tilages and  appear  externally  as  a  round  swelling  in 
which  a  systolic  pulsation  is  to  be  seen  and  felt.     This 
pulsation  is   in  some    cases  distinctly  expansile  in  character,  and 
differs    in  this  respect  from  the  up-and-down  motion  which  may 
be  communicated  to  a  tumor  of  the  chest  wall  by  the  beating  of  a 
normal  aorta.     The  tumor  is  usually  firm,  rarely  soft,  and  may  be 
as  hard  as  any  variety  of   malignant  new  growth.     Occasionally 


282  PHYSICAL   DIAGNOSIS. 

the  thickness  of  the  lamellated  clot  within  it  is  so  great  that  no 
pulsations  are  transmitted  to  the  surface. 

Whether  the  aneurism  penetrates  the  chest  or  not,  it  is  often 
possible  to  feel  over  it  a  vibrating  thrill,  usually  sys- 
tolic in  time.     If  the  layer  of  lamellated  clot  in  the 
sac  is  very  thick,  the  thrill  is  less  apt  to  be  felt. 

More  important  in  diagnosis  is  a  diastolic  shock  or  tap  which  is 
appreciated  by  laying  the  palm  of  the  hand  lightly  over  the  affected 


FIG.  152. — Aneurismal  Tumor  (A).    The  arrow  B  points  to  a  gumuiatous  swelling  neartheen- 
slform  cartilage.    The  radiographic  appearances  of  this  case  are  shown  below  (Fig.  155). 

area.     This  diastolic  shock  is  due  to  the  recoil  of  the  blood  in  the  di- 
lated aorta,  and  is  one  of  the  most  important  and  characteristic  signs 
Diastolic    ^  aneurism.      As  the  wall  of  the  sac  becomes  weaker, 
Shock,     the  intensity  of  this  shock  diminishes.     This  diastolic 
shock  may  be  appreciated  over  the  trachea  also,  and  is  thought  by 
some  to  have  even  more  significance  when  felt  in  this  situation. 

Of  special  importance  in  aneurism  of  the  transverse  arch  is  the 
sign  known  as  the  tracheal  tug.     The  arch  of  the  aorta  runs  over 


THORACIC  ANEURISM.  283 

the  left  primaiy  bronchus  in  such  a  way  that  when  the  aorta  is 

dilated,  the  bronchus  is  pressed  upon  with  each  expansile  pulsation 

Tracheal     °^  the  artery.     This  systolic  pressure  transmitted  to 

Tug.        the  trachea  produces  a  distinct  downward  tug  upon  it 

with  each  systole  of  the  heart.     The  tug  is  best  felt  by  making  the 

patient  throw  back  his  head  so  as  to  put  the  trachea  upon  a  stretch. 

The  physician  then  stands  behind  him  and  gently  presses  the  tips 

of  the  fingers  of  both  hands  up  under  the  lower  border  of  the  cri- 


FIG.  153— Aneurism  Tumor  Perforating  the  Sternum  at  A.    At  B  there  is  a  gummatous  mass. 
(See  below.  Fig.  155,  a  radiograph  of  this  case). 

coid  cartilage.  In  feeling  thus  for  the  tracheal  tug  as  transmitted 
to  the  cricoid  cartilage  certain  precautions  must  be  observed : 

(«.)  One  must  distinguish  the  tracheal  tug  from  a  simple  pulsa- 
tion transmitted  to  the  superficial  tissues  by  the  vessels  under- 
neath. Such  pulsation  makes  the  tissues  move  out  and  in  rather 
than  up  and  down. 

(ft)  A  tracheal  tug  felt  only  during  inspiration  has  no  patho- 
logical significance  and  is  frequently  present  in  health. 

While  preparing  to  try  for  the  tracheal  tug  we  may  notice 
whether  there  is  any  dislocation  of  the  trachea,  as  shown  by  the 


284  PHYSICAL  DIAGNOSIS. 

displacement  of  Adam's  apple.  Aphonia,  stridor,  cough,  dysphagia, 
and  other  symptoms  are  produced  by  pressure  on  gullet  and  windpipe. 
Other  signs  of  aneurism,  due  to  the  pressure  of  the  dilated  aorta 
upon  the  nerves  or  vessels  of  the  mediastinum,  are : 

(1)  Inequality  of  the  pupils. 

(2)  Inequality  of  the  radial  pulses. 

(3)  (Edema  and  cyanosis  of  one  arm  or  of  one  side  of  the  neck 
and  head. 

(4)  Pain  in  one  arm  from  the  pressure  of  an  aneurism  involving 
the  subclavian  artery  upon  the  brachial  plexus. 

(5)  Clubbing  of  the  fingers  of  one  hand  (rare). 

(6)  Prominence  of  one  eye  (rare). 

(7)  Flushing  or  sweating  of  one  side  of  the  face  (very  rare). 
Contraction  or  dilatation  of  the  pupil  is  due  to  a  paralytic  or 

irritative  affection  of  the  sympathetic  nerves.  This  symptom  is 
much  commoner  than  the  other  effect  of  pressure  upon  the  sympa- 
thetic nerves;  namely,  flushing  or  sweating  of  one  side  of  the  face. 

In  comparing  the  pulses  in  the  two  radials  we  must  bear  in  mind 
the  possibility  of  a  congenital  difference  between  them,  due  to  a 
difference  either  in  the  size  of  the  arteries  or  in  their  position,  and 
also  that  a  tumor  pressing  on  the  subclavian  may  affect  the  pulse 
exactly  as  an  aneurism.  The  pulse  wave  upon  the  affected  side 
(most  often  the  left)  may  be  either  less  in  volume  or  later  in  time 
than  the  wave  in  the  other  radial  artery,  according  as  the  pulse 
wave  is  actually  delayed  in  the  aneurismal  sac  or  merely  diminished 
by  it.  In  marked  cases  the  pulse  upon  the  affected  side  may  be 
nearly  or  quite  absent.  On  the  other  hand  the  inequality  of  the 
pulses  may  be  so  slight  that  the  sphygmograph  has  to  be  employed 
to  demonstrate  differences  in  the  shape  of  the  wave  not  perceptible 
to  the  fingers. 

Examination  of  the  heart  itself  may  show  some  dislocation  of 
the  organ  to  the  left  and  downward,  owing  to  the  direct  pressure 
of  the  aneurismal  sac,  but  no  enlargement. 

II.  Percussion. 

If  the  aneurism  is  deep-seated,  the  results  of  percussion  are 
negative.  If,  on  the  other  hand,  it  be  situated  immediately  be- 


THORACIC  ANEURISM. 


285 


neath  the  sternum  or  close  under  the  thoracic  wall,  an  area  of  dul- 

'» 

ness,  not  present  in  the  normal  chest,  may  be  mapped  out.     The 
outlines  most  commonly  seen  in  such  cases  are  shown  in  Fig.  154. 
When  the  aneurism  involves  the  descending  aorta,  an  area  of  dulness 
may  be  found  in  the  region  of  the  left  scapula  or  below  it,  and  pul 
sation  may  be  detected  in  the  same  area. 

III.  Auscultation. 

The  signs  revealed  by  auscultation  are  not  of  much  diagnostic 
value  as  a  rule.     In  about  one-half  of  the  cases  of  sacculated  aneu- 


He&rt  dulness. 


Liver  dulness..  •** 


FIG.  154.— Diagram  of  Percussion  Dulness  in  Aortic  Aneurism. 

rism  there  are  no  sounds  or  murmurs  to  be  heard  over  the  tumor. 
In  other  cases  a  systolic  murmur,  the  audible  counterpart  of  the 
vibratile  thrill,  may  be  heard  over  the  area  of  pulsation,  tumor,  qr 
dulness  corresponding  to  the  aneurismal  sac.  This  systolic  mur- 
mur may  be  due  to  many  causes  other  than  aneurism,  and  has  noth- 
ing characteristic  about  it.  A  similar  systolic  sound  is  sometimes 
heard  over  the  trachea  (Druniniond's  sign)  or  in  the  mouth,  if  the 
patient  closes  his  lips  around  the  pectoral  extremity  of  the  steth- 
oscope (Sansom's  sign). 

A  loud,  low-pitched  diastolic  sound,  corresponding  to  the  pal- 


PHYSICAL  DIAGNOSIS. 

pable  diastolic  ^shock,  is  generally  to  be  heard  in  the  aortic  region 
This  diastolic  sound,  which  is  probably  not  produced  by  the  aortic 
valves,  is  remarkably  deep-toned  and  loud,  and  is,  on  the  whole,  the 
most  important  sign  of  aneurism  revealed  by  auscultation. 

If  a  portion  of  either  lung  is  directly  pressed  upon  by  the  an- 
eurismal  sac,  we  may  have  the  signs  of  condensation  of  the  lung 
in  the  area  pressed  upon  (slight  dulness,  broncho-vesicular  breath- 
ing, and  exaggerated  voice  sounds).  If  one  of  the  primary  bronchi 


From  the  front. 


From  behind. 


FIG.  155.  -Radiograph  of  Case  whose  Photograph  is  Reproduced  as  Figs.  153  and  153.  In  the 
right-hand  cut  are  shown  the  appearances  seen  from  behind.  The  left-hand  cut,  A^  A. 
aneurismal  sac ;  B,  heart  displaced ;  C,  liver  (not  in  focus). 

is  pressed  upon,  as  occasionally  happens,  atelectasis  of  the  corre- 
sponding lung  may  be  manifested  by  the  usual  signs  (dulness,  ab- 
sence of  tactile  frernitus  and  of  respiratory  and  vocal  sounds). 

Since  aneurism  is  frequently  associated  with  regurgitation  at 
the  acirtic  valve,  a  diastolic  murmur  is  not  infrequently  to  be 
heard. 

If  the  aneurismal  sac  is  of  very  great  size,  the  pulse  wave  in 
the  femorals  may  be  obliterated,  as  happened  in  a  case  described 
by  Osier. 


THORACIC  ANEURISM. 
IT.   Radioscopy, 


287 


With  the  fluorosoope  and  through  photography  one  can  often 
make  out  a  shadow  corresponding  to  the  position  of  the  aneurism. 


FIG.  156.— Aortic  Aneurism.    (From  v.  Zlemssen's  Atlas.) 


The  position  of  the  shadow  is  best  explained  by  reference  to  Figs. 
155,  35(5,  and  157. 

Summary. 

The  most  important  signs  of  aneurism  are: 

1.  Abnormal  pulsation  —  visible  or  palpable 

2.  Tumor  over  which  a 

3.  Thrill  and  a 


288  PHYSICAL  DIAGNOSIS. 

4.  Diastolic  shock  may  be  felt. 

5.  Trachea!  tug. 

6.  Pressure  signs  (unequal  pulses,  pupils,  hoarseness,  pain,  etc  ) 

7.  Ihdness  on  percussion  over  the  suspected  area. 

8.  Loud,  low-pitched  aortic  second  sound. 

9.  Systolic  murmur  (least  important  of  all). 


FIG.  157.— Aneurism  of  the  Aorta.    (Curschman.) 

10.  Radioscopy  may  demonstrate  a  shadow  higher  up  than  that 
corresponding  to  the  heart  and  extending  beyond  that  produced  by 
the  sternum,  spinal  column,  and  great  vessels. 

Diagnosis  of  the  Seat  of  the  Lesion. 

(a)  Aneurism  of  the  ascending  arch  generally  approaches  or 
penetrates  the  chest  wall  in  the  vicinity  of  the  second  right  inter- 
costal space  near  the  sternum.  Previous  to  'perforating  the  thoracic 


THORACIC  ANEURISM.  289 

parietes,  the  growth  of  the  aneurism  may  give  rise  to  pain,  pulsa- 
tion, and  dulness  and  thrill  in  this  region. 

(b)  Aneurism  of  the  transverse  arch  or  diffuse  dilatation  of  the 
aorta,  which  is  the  most  common  of  all  types  of  aortic  aneurism, 
may  not  give  rise  to  any  visible  pulsation  of  the  chest  wall,  and,  if 
deep-seated,  need  not  produce  any  abnormal  dulness  on  percussion. 
In  such  cases  an  aneurism  is  to  be  recognized,  if  at  all,  by  evidences 
of  pressure  on  the  nerves  or  vessels  of  the  mediastinum  (cough, 
aphonia,  inequality  of  the  pupils,  tracheal  tug,  etc.). 

(c)  Aneurism  of  the  descending  aorta  gives  rise  usually  to  severe 
and  persistent  pain  in  the  back,  which  radiates  along  the  intercos- 
tal nerves  or  downward.     Other  pressure  symptoms  are  not  marked, 
but  in  advanced  cases  an  area  of  abnormal  dulness  and  pulsation 
may  be  found  in  the  region  of  the  left  scapula  or  below  it. 

(d)  If  the  innominate  artery  or  one  of  the  carotids  is  involved, 
we  usually  find  a  pulsating  lump  in  the  region  of  one  or  the  other 
claviculo-sternal  joint  or  at  the  root  of  the  neck,  and  the  trachea 
may  be  displaced  to  one  side.     This  form,  however,  is  distinctly 
rare.     The  violent  throbbing  and  dilated  carotid  of  aortic  leakage 
is  often  mistaken  for  it. 

Differential  Diagnosis. 

(a)  It  is  important  to  distinguish  the  diffuse  dilatation  of  the 
aortic  arch,  which  sooner  or  later  complicates  almost  every  case  of 
incompetency  of  the  aortic  valves,  from  saccular  aneurism  of  the 
transverse  aorta.  Dulness  and  pulsation,  perhaps  with  systolic  mur- 
mur and  thrill  in  the  second  and  third  right  interspaces  near  the 
sternum,  occur  in  many  cases  of  aortic  regurgitation,  but  though 
the  aorta  is  dilated,  its  coats  are  not  ruptured  and  it  never  breaks. 
The  absence  of  pressure  signs  (pain,  aphonia,  etc.)  distinguishes  it 
from  true  aneurism. 

(&)   Aneurism  is  not  infrequently  mistaken  for  aortic  stenosis,  in 

which  a  systolic  murmur  and  thrill,  similar  to  those  occurring  in 

aneurism,  are  to  be  heard  over  the  region  of  the  aortic  arch.     From 

aortic  stenosis  aneurism  is  distinguished  by  the  fact  that  it  does 

19 


290  PHYSICAL  DIAGNOSIS. 

not  produce  chai  acteristic  changes  in  the  pulse,  and  by  the  presence 
of  some  one  of  the  symptoms  above  described,  such  as  tracheal 
tug,  pressure  symptoms,  abnormal  area  of  percussion  dulness,  etc. 

(c)  Simple  dynamic  throbbing  of  a  normal  aortic  arch  similar 
to  that  which  occurs  in  the  abdominal  aorta  may  lift  the  chest  wall 
so  as  to  simulate    aneurism.     The   other  positive  symptoms  and 
signs  of  aneurism  are,  however,  absent. 

(d)  Pulmonary  tuberculosis  or  cancer  of  the  oesophagus,  produc- 
ing as  they  may  substernal  pain,  cough,  and  aphonia  by  pressure 
upon   mediastinal   structures,   have   been  mistaken  for   aneurism, 
from  which,  however,  they  may  be  distinguished  by  the  absence  of 
the  positive  signs  above  described,  by  the  more  rapid  emaciation 
of  the  patient,  and  by  the  positive  evidences  of  cancer  or  tubercu- 
losis. 

(e)  Empyema  necessitatis  may  produce  a  pulsating  tumor  like 
that  of  aneurism  and  the  area  of  dulness  may  be  similar,  but  there 
is  no  diastolic  shock,  no  tactile  thrill  or  murmur,  and  the  history 
of  the  case  is  usually  very  different  from  that  of  aneurism.     It  is 
perfectly  safe  to  insert  a  fine  hollow  needle  in  doubtful  cases.     No 
serious  hemorrhage  results  if  aneurism  is  present,  and  the  diagnosis 
and  treatment  may  be  greatly  assisted. 

(/)  Mediastinal  tumors  are  sometimes  almost  indistinguishable 
from  aneurism  during  life.  They  may  produce  a  more  intense  and 
widespread  dulness  which  is  usually  in  the  median  line,  while  the 
dulness  of  aneurism  is  of  tener  at  one  side.  The  pulsation  transmit- 
ted to  a  tumor  by  the  heart  has  not  the  expansile  character  of  aneu- 
rismal  pulsation.  Tumors  are  not  associated  with  any  diastolic 
shock,  rarely  with  a  tracheal  tug. 

The  course  of  most  mediastinal  tumors  is  progressive  and  at- 
tended by  great  cachexia,  while  the  symptoms  ^i  aneurism  are  often 
more  or  less  intermittent,  and  unless  pain  i  ^  sever'  there  is  no  such 
emaciation  or  anaemia  as  is  commonly  seen  with  mediactinol  tu- 
mors. Pressure  symptoms  may  be  the  same  in  both  diseases,  but 
are  usually  more  marked  with  mediastinal  growths.  A  metastatic 
nodule  over  the  clavicle  sometimes  betrays  the  presence  of  a  pri- 
mary focus  within  the  chest. 


THORACIC  ANEURISM.  291 

(<7)  Retraction  of  the  right  lung  (fibroid  phthisis),  with  or  without 
displacement  of  the  heart  toward  the  diseased  side,  may  uncover 
the  heart  so  as  to  produce  some  of  the  signs  of  aneurism,  i.e.,  pul- 
sation and  dulness  in  the  upper  right  intercostal  spaces  near  the 
sternum,  with  a  loud  aortic  second  sound  and  sometimes  a  systolic 
murmur  in  the  dull  area.. 

The  history  of  the  case  and  a  careful  examination  of  the  lungs 
usually  suffice  to  set  us  right. 

(A)  Dilatation  of  the  heart  may  be  so  extreme  that  pulsation 
and  percussion  dulness  appear  in  the  characteristic  aneurismal  area 
to  the  right  of  the  sternum,  especially  if  there  is  solidification  of 
the  left  lung.  But  the  pulse  is  in  such  cases  much  weaker  and 
more  irregular  than  is  to  be  expected  in  uncomplicated  cases  of  aortic 
aneurism,  and  the  history  of  the  case  is  usually  decisive. 

By  the  same  marks  we  can  distinguish  the  pulsations  of  a 
dilated  heart,  which  sometimes  appear  in  the  left  hypochondrium. 


CHAPTER   XIV. 
DISEASES  OF  THE   LUNGS. 

BRONCHITIS,  PNEUMONIA,    TUBERCULOSIS. 

I.   TKACHEITIS. 

IN  connection  with  bronchitis  or  as  a  forerunner  thereof,  inflam- 
mation of  the  trachea  is  not  uncommon.  It  gives  rise  to  no  char- 
acteristic physical  signs,  but  is  to  be  suspected  when  the  patient 
complains  of  cough  with  pain  over  the  upper  portion  of  the  sternum 

BRONCHITIS. 

Inflammation  of  the  larger  bronchial  tubes  is  not  often  the 
cause  of  any  definite  physical  signs,  but  with  every  paroxysm  of 
coughing  the*  patient  may  feel  pain  in  an  area  corresponding  ex- 
actly to  the  anatomical  position  of  the  primary  bronchi.  I  have 
seen  patients  indicate  most  accurately  the  situation  of  the  large 
tubes  when  pointing  out  the  position  of  pain  produced  by  coughing. 

In  the  vast  majority  of  cases  of  acute  bronchitis  the  smaller 
bronchi  are  involved,  and  the  swelling  of  their  walls,  with  or  with- 
out exudation,  is  manifested  by  the  following  physical  signs : ' 

(1)  Diminution  in  the  intensity  of  vesicular  breathing  over  the 
area  affected  (rarely  in  the  earliest  stages  the  breath  sounds  are 
exaggerated  and  harsh,  especially  in  the  upper  portions  (>f  the 
chest). 

1  Bronchitis  may  exist  without  rales,  but  cannot  be  diagnosed  without 
them.  Occasionally  they  are  present  only  in  the  early  morning. 


BRONCHITIS,   PNEUMONIA,    TUBERCULOSIS.  293 

(2)  Rales,  which  are  squeaking  or  piping  over  bronchi  which 
are  narrowed  without  any  considerable  amount  of  exudation,  as  is 
the  case  in  the  earliest  stages  of  many  cases,  and  bubbling,  crack- 
ling, or  clicking  in  later  stages,  when  watery  or  viscid  exudation  is 
present  in  the  tubes.  The  calibre  of  the  bronchi  affected  can  be 
estimated  from  the  coarseness  or  fineness  of  the  rales.  Low-pitched 
groaning  sounds  point  to  a  stenosis  of  a  relatively  large  bronchus, 
while  squeaking  and  whistling  sounds  are  usually  produced  in  the 
smaller  tubes.  Large,  bubbling  rales  are  much  less  often  heard 
than  the  finer,  crackling  variety.  The  latter  are  produced  in  the 
smallest  tubes,  the  former  in  the  larger  variety. 

Simple  non-tuberculous  bronchitis  is  almost  invariably  bilateral 
or  symmetrical,  and  affects  most  often  the  lower  two-thirds  of  the 
lungs,  leaving  the  apices  relatively  free.  It  is  almost  never  con- 
fined to  an  apex.  When  rales  are  to  be  heard  on  one  side  of  the 
chest  only,  and  when  they  persist  in  the  same  spot  for  days  and 
weeks,  tuberculosis  is  always  to  be  suspected,  especially  if  the 
rales  are  localized  at  the  summit  of  one  or  both  lungs.  It  should 
never  be  forgotten  that  the  tubercle  bacillus  is  capable  of  exciting 
a  bronchitis  indistinguishable  from  other  varieties  of  bronchitis, 
except  by  its  tendency  to  show  itself  at  the  apex  of  the  lung  and 
on  one  side  only ;  most  cases  of  pulmonary  tuberculosis  begin  in 
this  way. 

The  only  other  variety  of  bronchitis  which  is  often  unilateral  is 
that  due  to  the  influenza  bacillus.  In  the  course  of  a  case  of  influ- 
enza, a  unilateral  localized  bronchitis  not  infrequently  occurs.  Over 
a  patch  of  lung,  perhaps  the  size  of  the  palm  of  the  hand,  fine,  moist 
rales  may  persist  for  weeks,  finally  clearing  up  only  after  the  pa- 
tient has  resumed  his  ordinary  occupation.  Doubtless  such  local- 
ized patches  of  bronchitis  are  often  accompanied  by  foci  of  lobular 
pneumonia  too  small  to  be  detected  by  our  present  methods  of 
physical  examination. 

Percussion  dulness  is  absent  in  bronchitis  except  near  the  end 
of  fatal  cases,  when  the  lung  is  stuffed  with  mucus  and  pus,  or 
when  atelectasis  has  occurred  owing  to  extensive  plugging  of  the 
larger  bronchi.  These  events  are  rarely  seen,  and  in  general  the 


294  PHYSICAL  DIAGNOSIS. 

negative  results  of  percussion  are  of  great  value  in  excluding  sol- 
idification or  fluid  exudation. 

Occasionally  percussion  resonance  may  be  increased  owing  to 
a  slight  temporary  overdistention  of  the  air  vesicles  from  coughing.1 

Inspection  usually  shows  little  or  nothing  of  diagnostic  impor- 
tance in  acute  bronchitis.  Long-standing  cases,  complicated  as 
they  almost  invariably  are  by  emphysema,  present  changes  in  the 
shape  of  the  thorax ;  but  these  are  due  to  the  emphysema  rather 
than  to  the  bronchitis.  In  children  acute  bronchitis  sometimes 
involves  so  many  of  the  smaller  bronchi  that  dyspnoea  and  use  of 
accessory  muscles  of  respiration  are  notable.  But  this  usually 
means  atelectasis,  broncho-pneumonia,  or  laryngeal  spasm,  in  addi- 
tion to  the  bronchitis. 

From  violent  coughing  the  jugulars  may  be  distended,  but  no 
systolic  pulsation  occurs  in  them. 

Voice  sounds  and  tactile  fremitus  are  normal. 

Differential  Diagnosis. 

(Edema  of  the  lung  and  bronchial  asthma  are  the  only  pathologi- 
cal processes  (except  hemorrhage  into  the  lung  substance)  which 
give  rise  to  signs  like  those  of  bronchitis. 

(1)  In  oedema  of  the  lung,  or  in  pulmonary  apoplexy,  one  may 
find,  as  in  simple  bronchitis,  a  diminished  vesicular  breathing  with 
crackling  riales,  but  oedema  of  the  lung  is  almost  always  best  marked 
in  the  dependent  portions;   that  is,  in  the  posterior  parts  of  the 
lung  if  the  patient  has  been  lying  upon  the  back,  or  in  the  lower 
lobes  if  he  has  been  sitting  up.     The  rales  of  osdema  are  mostly 
bubbles,  and  are  more  uniform  in  size  when    compared  to  those  of 
bronchitis.     The  recognition  of   a   cause  for   the  oedema,  for  ex- 
ample   a   non-compensated   heart   lesion,  materially   aids    in   the 
diagnosis. 

(2)  Bronchial  asthma  or  spasm  of  the  finer  bronchi  produces  dry 
squeaking  and  groaning  sounds  similar  to  those  heard  in  the  earlier 

'In  children  examined  during  a  crying-spell  a  cracked-pot  sound  can 
usually  be  elicited  by  percussion.  This  is  in  no  way  characteristic  of  bron- 
chitis and  can  often  be  obtained  in  healthy  infants. 


BRONCHITIS,  PNEUMONIA,   TUBERCULOSIS. 


295 


stages  of  many  cases  of  bronchitis.     But  in  bronchial  asthma  the 
rales  are  chiefly  expiratory^  and  expiration  is  prolonged  and  inten- 
sified.   Moreover,  the  inhalation  of  a  few  drops  of  auiyl  nitrite  will 
temporarily  dispel  rales  due  to  bronchial 
spasm,  while  on  the  rales  of  dry  bronchitis 
it  has  no  effect  (Abrarns). 

(3)  Broncho-pneumonia.        In     many 
cases  of  lobular  or  broncho-pneumonia  the 
physical  signs  are  exclusively  those  of  the 
coexisting  bronchitis.     In  such  cases  the 
diagnosis  of  bronchitis  is  not  wrong,  but 
does  not  cover  the  whole  ground.    I  shall 
discuss  further  under  broncho-pneumonia 
the  evidence  which  leads  us  to    suspect 
that  something  more   than   bronchitis   is 
present. 

(4)  Muscle    sounds.       Under     certain 
circumstances    (cold,    nervousness),    the 
rumbling    noises    produced    by   muscular 
contractions  in  the  chest  wall  may  simu- 
late rales  so  closely  that  the  diagnosis  of 
bronchitis    may   be    strongly    suggested. 
The    differentiation    between    rales    and 
muscle  sounds  has  already  been  discussed 
(see  above,  p.  146). 

(5)  Atelectatic   crepitation.     Crackling 
rales  heard  over  the  thin  margins  of  the 
lungs  at  the  base  of  the  axilla  or  along 
the  edges  of  the  rnanubrium  are  often  due 

to  atelectasis  (see  above).  From  bronchitis  they  are  distinguished 
by  their  situation  and  by  the  lack  of  symptoms.  They  are  best 
heard  at  the  point  shown  in  Fig.  158. 

Chronic  Bronchitis. 

So  far  as  the  bronchitis  itself  is  concerned,  there  may  be  no 
difference  in  the  physical  signs  between  the  acute  and  chronic  forms 


FIG.  158.— The  Dots  are  Placed 
over  the  Area  where  Atelecta- 
tic Crepitation  is  Oftenest 
Heard. 


296  PHYSICAL  DIAGNOSIS. 

of  the  disease;  but  in  the  latter  one  almost  invariably  finds  associ- 
ated with  the  bronchitis  itself  a  considerable  degree  of  emphysema, 
of  asthma,  and  of  bronchiectasis.  Indeed,  the  foreground  of  the 
clinical  picture  and  the  bulk  of  the  physical  signs  are  made  up  by 
these  three  diseases,  rather  than  by  the  bronchitis  itself.  Accord- 
ingly, I  shall  not  discuss  chronic  bronchitis  any  -further  at  this 
point,  but  will  return  to  the  subject  in  the  chapters  on  Emphysema 
and  on  Bronchiectasis. 

CKOUPOUS  PNEUMONIA. 

In  its  typical  form  croupous  or  fibrinous  pneumonia  produces 
solidification  of  one  or  more  lobes,  usually  the  lower,  the  process 
being  accurately  bounded  by  the  interlobular  fissures.  Although 
the  physical  signs  of  the  earlier  stages  differ  considerably  from 
those  of  the  later  ones,  there  seems  to  be  no  sufficient  ground  for 
marking  off  stages  of  engorgement  and  of  red  and  gray  hepatiza- 
tion,  for  clinically  these  stages  cannot  be  distinguished. 

The  solidification  may  begin  in  the  deeper  parts  of  the  lung 
("central pneumonia"},  so  that  no  physical  signs  are  obtainable 
unless,  later  in  the  course  of  the  disease,  the  process  extends  to  the 
surface  of  the  lung. 

Massive  pneumonia^  in  which  the  bronchi  as  well  as  the  air  cells 
are  plugged  with  fibrin  and  leucocytes,  is  a  relatively  rare  form  of 
the  disease,  but  possesses  great  clinical  importance  on  account  of  the 
marked  resemblance  between  its  physical  signs  and  those  of  pleural 
effusion. 

The  frequency  of  endocarditis  and  pericarditis  in  connection 
with  lobar  pneumonia,  especially  with  those  of  the  left  side,  should 
be  borne  in  mind. 

Physical  Signs. 

(a)  Inspection. — The  aspect  of  the  patient  frequently  suggests 

the  diagnosis;  the  face  is  anxious,  often  flushed  or  slightly  cya- 

nosed,  the  flush  sometimes  affecting  most  strikingly  the  side  of  the 

face  corresponding  to  the  lung  affected.1     Herpetic  vesicles  ("cold 

1  Perhaps  because  the  patient  is  apt  to  lie  upon  the  affected  side. 


BRONCHITIS,   PNEUMONIA,    TUBERCULOSIS.  297 

sores  ")  are  often  to  be  seen  around  the  mouth  or  nose.  The  rapid, 
difficult  breathing  is  at  once  noticable,  and  expiration  is  often  ac- 
companied by  a  grunt.  The  use  of  the  accessory  muscles  of  respi- 
ration and  the  dilatation  of  the  nostrils  attract  attention. 

The  combination  of  marked  dyspnoea  with  absence  of  dropsy  is 
met  with  more  frequently  in  pneumonia  than  in  any  other  disease. 
Both  sides  of  the  chest  usually  move  alike,  but  occasionally  the 
affected  side  shows  deficient  expansion  especially  in  the  later  stages 
of  the  disease,  and  the  other  side  of  the  chest  shows  increased  re- 
spiratory movements  (compensatory).  Rarely  the  pulsations  of  the 
heart  may  be  transmitted  to  the  chest  wall  through  the  affected  lung. 

When  pneumonia  attacks  a  feeble  old  man,  or  follows  injuries 
(surgical  pneumonia),  its  onset  may  be  insidious,  and  none  of  the 
phenomena  just  described  may  be  seen. 

(5)  Palpation. — In  the  great  majority  of  cases  tactile  fremitus  is 
markedly  increased  over  the  affected  area,1  but  in  case  the  bronchi 
are  occluded  by  secretions  or  fibrinous  exudate,  fremitus  may  be  di- 
minished or  altogether  absent.  A  few  hard  coughs  will  sometimes 
clear  out  the  tubes  and  thus  materially  assist  the  diagnosis.  Occa- 
sionally an  increase  in  superficial  temperature  of  the  affected  side 
may  be  noticed  by  palpation,  and  rarely  one  feels  a  friction  rub 
due  to  the  fibrinous  pleurisy  which  almost  invariably  accompanies 
the  disease. 

(c)  Percussion. — Over  the  area  affected  the  percussion  note  is  gener- 
ally dull  and  may  be  almost  flat,  except  in  the  earliest  and  latest 
stages  of  the  disease,  in  which  it  may  have  a  tympanitic  quality  with 
or  without  an  element  of  slight  dxilness.  More  marked  tympany  is 
usually  present  over  the  unaffected  lobes  of  the  diseased  lung  (that 
is,  over  the  upper  lobes  in  the  great  majority  of  cases.) 

The  conditions  just  described  represent  the  great  majority  of 
cases,  but  the  following  exceptions  occur : 

(1)  In  the  pneumonias  of  children,  and  occasionally  in  adults, 
dulness  may  be  absent. 

1  By  using  the  edge  instead  of  the  flat  of  the  hand  the  boundaries  of  sol- 
idified lobes  may  often  be  very  accurately  marked  out  by  means  of  the  tactile 
fremitus. 


298  PHYSICAL  DIAGNOSIS. 

(2)  When  the  lower  lobe  of  the  left  lung  is  affected,  a  distinctly 
tympanitic  quality  may  be  transmitted  to  the  consolidated  area 
from  a  distended  stomach  or  colon. 

(3)  In  rare  cases,  the  percussion  over  the  consolidated  area  may 
be  of  a  metallic  quality,  or  produce  the  "  cracked-pot "  sound. 

(4)  In  central  pneumonia  there  may  be  no  change  in  the  percus- 
sion note,  or  it  may  be  unusually  full  and  deep  so  that  the  sound 
side  seems  dull  by  comparison. 

A  solidified  lobe  increases  so  much  in  size  that  the  area  of  dul- 
ness  corresponding  to  it  often  seems  incredibly  large.  Thus,  al- 
though the  lower  lobe  reaches  in  health  not  more  than  half-way  up 
the  scapula,  when  solidified  it  produces  dulness  throughout  nearly 
the  whole  back. 

The  right  base  is  the  most  frequent  seat  of  pneumonic  solidifica- 
tions,  but  the  dulness  corresponding  to  it  is  often  first  noticeable  in 
the  posterior  axillary  line.  A  dulness  appreciable  only  in  the  front 
of  the  chest  is  almost  sure  to  correspond  to  the  upper  lobe,  while 
signs  in  the  lower  part  of  the  right  axilla  correspond  to  the  middle 
lobe.  Many  cases  of  central  pneumonia  first  appear  at  the  surface 
in  one  or  the  other  axilla. 

As  regards  the  amount  of  solidification  needed  to  produce  per- 
cussion dulness,  Wintrich  says  that  the  minimum  is  a  patch  5  cm. 
in  diameter,  2  cm.  deep,  and  superficially  situated. 

Percussion  often  makes  us  aware  of  an  increased  resistance  or 
diminished  elasticity  of  the  affected  side,  although  the  resistance  is 
seldom  as  marked  as  in  large  pleural  effusions. 

(d)  Auscultation. — In  the  great  majority  of  cases  typical  tubular 
breathing  is  to  be  heard  over  the  affected  area.  Since  a  whisper 
is  practically  a  forced  expiration,  this  tubular  quality  is  very  well 
brought  out  if  the  patient  is  made  to  whisper  "one,  two,  three," 
or  any  other  succession  of  syllables,  and  by  this  method  the  fatigue 
and  pain  of  deep  breathing  may  be  saved.  By  this  use  of  the 
whispered  voice  one  may  accurately  mark  out  the  boundaries  of  the 
consolidated  area,  and  demonstrate  in  many  cases  that  it  coincides 
with  the  boundaries  of  one  lobe  of  the  lung. 

In  the  earliest  stages  of  the  disease  the  breathing  may  be  bron- 


BRONCHITIS,   PNEUMONIA,   TUBERCULOSIS.  299 

cho-vesicular ;  more  often  it  is  feeble  or  suppressed  over  the  con- 
solidated area,  and  "crepitant  rales,"  that  is,  very  fine  crackling 
sounds,  may  be  heard  at  the  end  of  inspiration,  but  these  are  much 
more  common  in  the  stage  of  resolution1  ("crepitans  redux"). 

If  some  of  the  smaller  bronchi  are  blocked,  as  is  not  infre- 
quently the  case,  respiration  is  absent  or  very  feeble,  and  such 
cases  are  often  mistaken  for  pleuritic  effusion.  In  pneumonia  of 
the  upper  lobe  it  is  not  rare  for  bronchial  breathing  to  be  absent 
even  without  plugging  of  the  bronchi. 

In  cases  of  "central  pneumonia,"  that  is,  when  the  area  of 
solidification  is  in  the  interior  of  the  organ,  there  may  be  no 
change  in  the  breath  sounds,  or  a  bronchial  element  may  be  faintly 
audible  on  auscultation  with  the  unaided  ear,  and  only  by  this 
method. 

The  intensity  of  the  spoken  or  whispered  voice  is  greatly  in- 
creased over  the  area  of  consolidation,  and  sometimes  the  words 
can  be  distinguished.  The  nasal  twang  known  as  "  egophony  "  is 
occasionally  to  be  heard.  In  the  majority  of  cases,  as  has  been 
already  stated,  the  right  lower  lobe  posteriorly  is  affected,  so  that 
the  consolidated  area  is  immediately  in  apposition  with  the  spinal 
column.  Under  these  circumstances,  it  is  not  -  ;  all  uncommon  to 
hear  bronchial  breathing  transmitted  from  the  consolidated  lobe 
to  a  narrow  zone  close  along  the  spinal  column  on  the  sound  side. 
Such  a  zone  is  often  mistaken  for  consolidation  (see  Fig.  159). 

The  signs  are  usually  less  marked  in  the  axilla  and  in  the  front 
of  the  lung,  but  in  a  minority  of  cases,  and  especially  when  the 
upper  lobes  are  affected,  the  signs  are  wholly  in  the  front.  When 
searching  for  evidences  of  consolidation  in  persons  suspected  to 
have  pneumonia,  one  should  never  omit  to  examine  the  apices  and 
very  summit  of  the  armpit,  pressing  the  stethoscope  up  behind  the 
anterior  fold  of  the  axilla. 

In  examining  the  posterior  lobes,  when  the  patient  is  too  weak 
to  sit  up  and  is  loath  even  to  turn  upon  the  side,  the  Bowles  steth- 

1  Crepitant  rales  are  rarely  heard  in  the  pneumonias  of  infancy  and  old 
age.  They  are  not  peculiar  to  pneumonia,  but  occur  in  pulmonary  oedema  or 
hemorrhagic  infarction— conditions  easily  distinguished  from  pneumonia. 


300 


PHYSICAL  DIAGNOSIS. 


oscope  is  a  great  convenience,  owing  to  the  ease  with  which  its  flat- 
tened extremity  may  be  worked  in  between  the  patient  and  the  bed- 
clothes without  causing  any  discomfort. 

When  resolution  begins,  the  signs  may  suddenly  and  completely 
disappear  within  a  few  hours.  More  frequently  the  bronchial 
breathing  is  modified  to  broncho-vesicular,  dulness  and  broncho- 
phony  become  less  marked,  fine  crackling  rales  (crepitans  redux) 
or  coarser  moist  bubbles  appear,  and  the  lung  gradually  returns  to 
its  normal  condition  within  a  period  of  three  or  four  days.  In  the 


^^.-Tympany. 


Bronchial  breathing 

transmitted  by 

spinal   column  to 
sound  lung. 


Solidification. 


FIG.  159.-  Diagram  of  Signs  in  Pneumonia. 

active  stages  of  the  disease  the  entire  absence  of  rales  is  very  char- 
acteristic. In  about  19  per  cent,  of  the  cases  the  solidification  of 
the  lung  persists  after  the  fall  of  the  temperature ;  indeed,  it  may 
be  weeks  or  even  months  before  it  clears  up,  and  yet  the  lung  may 
be  perfectly  sound  in  the  end.  On  the  other  hand,  abscess  or  gan- 
grene or  fibrosis  may  develop  in  the  solidified  lobe.  Commonest 
and  most  important,  however,  is  the  post-pneumonic  empy<>ni<i 
(basal  or  interlobar)  which  is  often  mistaken  for  delayed  resolu- 
tion. The  latter  is  rare;  empyema,  common  (see  below,  p.  349). 
"  Wandering  pneumonia"  is  a  term  applied  to  cases  in  which 


BRONCHITIS,  PNEUMONIA,   TUBERCULOSIS.  301 

the  consolidation  disappears  in  one  lobe  only  to  reappear  in  another, 
or  spreads  gradually  from  lobe  to  lobe.  The  physical  signs  in  such 
cases  do  not  differ  essentially  from  those  already  described. 

Summary. 

In  a  typical  case  one  finds  (oftenest  at  the  right  base  behind) 

1.  Duluess  on  percussion. 

2.  Increased  tactile  fremitus  and  voice  sounds. 

3.  Tubular  breathing  and  occasionally  crepitant  rales. 

These  signs  occurring  in  connection  with  fever,  cough,  rusty 
sputa,  pain  in  the  side,  dyspnoea,  and  herpes,  are  sufficient  for  the 
diagnosis. 

But  many  cases — some  say  the  majority — are  not  typical  when 
first  seen.  The  following  are  the  commonest  anomalies : 

(a)  There  may  be  tympany  instead  of  dulness,  especially  in 
children  or  when  the  solidification  is  at  the  left  base. 

(b)  The  breathing  may  be  feeble  but  vesicular  in  character,  or 
it  may  be  absent,  in  case  bronchi  are  plugged ;  from  the  same  cause 

(c)  Tactile  fremitus  may  be  diminished. 

A  hard  cough  may  clear  out  the  bronchi  and  produce  a  sudden 
metamorphosis  of  the  physical  signs  with  a  return  to  the  normal 
type. 

In  these  atypical  cases,  we  have  to  fall  back  upon  the  symp- 
toms, the  history,  the  blood,  and  sputa  for  help  in  the  diagnosis. 

Deep-seated  pneumonic  processes  may  appear  at  the  surface  in 
out-of-the-Avay  places,  e.g.,  at  the  summit  of  the  axilla,  and  the 
area  of  demonstrable  physical  signs  may  be  no  larger  than  a  silver 
dollar.  A  thorough  examination  of  every  inch  of  the  chest  is 
therefore  essential  in  doubtful  cases. 

In  the  later  stages  of  the  disease  crepitant  or  other  fine  rales 
often  appear,  and  the  signs  of  solidification  suddenly  or  gradually 
disappear. 

Differential  Diagnosis. 

Pneumonic  solidification  is  to  be  distinguished  from 

(1)  Pleuritic  effusion,  serous  or  purulent. 

(2)  Tuberculosis  of  the  lung. 


302  PHYSICAL  DIAGNOSIS. 

(1)  From  pleuritic  effusion,  pneumonia  is  to  be  distinguished 
in  the  great  majority  of  cases  by  differences  in  the  onset,  course, 
and  general  symptoms  of  the  disease.     In  pneumonia  the  patient  is 
far  more  suddenly  and  violently  attacked,  the  dyspnoea  is  much 
greater,  cough  and  pain  are  more  distressing  and  more  frequent, 
the  temperature  is  higher,  and  the  sputum  often  characteristic.    In 
pleuritic  effusion  the  dulness  is  usually  more,  in  tense  than  in  pneu- 
monia.    Tactile  fremitus  and  voice  sounds  are  increased  in  pneu- 
monia (except  when  the  bronchi  are  plugged) ;  decreased  or  absent 
in  pleuritic  effusion.     Bronchial  breathing  may  be  heard  in  both 
diseases,  but  is  usually  feeble  and  distant  when  occurring   in  pleu- 
risy, and  loud  in  pneumonia.     If  the  affection  be  on  the  left  side, 
the  diagnosis  is  much  aided  by  the  presence  of  dislocation  of  the 
heart,  which  is  produced  by  pleuritic  effusion  and  never  by  pneu- 
monia.    In  cases  of  pneumonia  with  occluded  bronchi,  one  may 
have  every  sign  of  pleuritic  effusion — flatness,  absent  breathing, 
voice  and  fremitus — and  in  such  cases  the  absence  of  any  disloca- 
tion of  the  heart,  provided  the  disease  is  upon  the  left  side,  is  very 
important.     If  a  similar  condition  of  things  occurs  upon  the  right 
side,  one  may  have  to  fall  back  upon  the  symptoms  and  upon  such 
evidence  as  the  blood  count,  herpes,  sputum,  etc. 

(2)  Tuberculosis  of  the  lung  causing,  as  it  may,  a  diffuse  sol- 
idification of  the  organ,  may  be  indistinguishable  from  pneumonia 
if  we  take  account  only  of  the  physical  signs,  but  the  two  diseases 
can  usually  be  distinguished  without  difficulty  by  the  difference  in 
their  symptoms  and  course,  and  by  the  presence  or  absence  of  tuber- 
cle bacilli  in  the  sputum. 

INHALATION  PNEUMONIA.     ASPIRATION  PNEUMONIA. 

When  food  or  other  foreign  substances  are  drawn  into  the  air 
passages,  as  may  occur,  for  example,  during  recovery  from  ether 
narcosis,  a  form  of  broncho-pneumonia  may  be  set  up,  in  which  the 
solidified  patches  are  not  infrequently  large  enough  to  be  recognized 
by  the  ordinary  methods  of  physical  examination. 

The  lesions  are  usually  bilateral  and  accompanied  by  a  general 
bronchitis.  Slight  dulness  and  indistinct  bronchial  breathing  can 


BRONCHITIS,   PXEUMOXIA,    TUBERCULOSIS.  303 

usually  be  made  out  over  an  irregular  area  in  the  backs  of  both 
lungs. 

The  signs  are  considerably  less  marked  than  in  croupous  pneu- 
monia, and  the  boundaries  of  the  irregular  patches  of  disease  do 
not  correspond  to  those  of  a  lobe  of  the  lung. 

If  not  rapidly  fatal,  the  disease  may  be  complicated  by  pulmo- 
nary gangrene  or  abscess  and  large  quantities  of  fetid  pus  may  be 
spit  up. 

BRONCHO-PNEUMONIA. 

(Catarrhal  or  Lobular  Pneumonia.) 

Multiple  small  areas  of  solidification  scattered  through  both 
lungs,  interspersed  with  areas  of  collapse,  and  usually  associated 
with  diffuse  bronchitis,  occur  very  frequently  in  children  producing 
severe  dyspnoea,  cyanosis,  cough,  and  somnolence,  and  running  a 
very  fatal  course. 

The  solidified  lobules  may  fuse  so  as  to  form  considerable  areas 
of  hepatized  lung,  or  there  may  be  no  lesion  larger  than  a  pea. 

This  is  the  usual  type  of  "lung  fever"  in  infants,  although  or- 
dinary lobar  pneumonia  is  fully  as  common  in  older  children. 

The  widespread  atelectasis  of  the  lower  lobes  which  is  associated 
with  the  disease  in  most  cases  owing  to  the  plugging  of  the  bronchi 
with  tenacious  secretions,  is  probably  as  serious  in  its  effects  as  the 
pneumonic  foci  themselves. 

The  anterior  and  upper  parts  of  the  lungs  often  become  dis- 
tended with  air  (vicarious  emphysema)  and  render  the  physical 
signs  very  confusing  and  deceptive. 

Physical  Signs. 

In  the  majority  of  cases  there  are  no  characteristic  physical 
signs,  and  the  diagnosis  has  to  be  made  largely  from  the  symptoms 
and  course  of  the  disease.  The  consolidated  areas  are  usually  too 
small  to  give  rise  to  any  dulness  on  percussion,  or  to  any  change  in 
the  breath  sounds,  voice  sounds,  or  fremitus,  so  that  auscultation 
shows,  as  a  rule,  nothing  more  than  patches  of  fine  rales  occurring 
at  the  end  of  expiration.  Localized  tympanitic  resonance  is  some- 


304  PHYSICAL  DIAGNOSIS. 

times  present  over  the  diseased  area,  making  the  sounder  portions 
of  the  lungs  seem  dull  by  comparison.  Occasionally,  whp.n  many 
lobules  have  fused  into  a  single  mass  of  larger  area,  the  ordinary 
signs  of  consolidation  may  be  obtained,  although  they  are  apt  to 
disappear  within  twenty-four  or  forty-eight  hours  and  appear  in 
another  situation.  As  above  said,  the  diagnosis  is  usually  to  be 
made,  if  at  all,  from  the  combination  of  the  physical  signs  of  a 
localized  bronchitis  with  the  symptoms  of  pneumonia.  "  This  pa- 
tient," we  say,  "has  only  the  signs  of  bronchitis,  but  he  is  too 
sick.  The  cyanosis,  dyspnoea,  and  fever  are  too  marked.  He  is 
sicker  than  simple  bronchitis  will  account  for." 

Differential  Diagnosis. 

(«)  Acute  pulmonary  tuberculosis  may  be  indistinguishable  from 
broncho-pneumonia  by  the  physical  signs  alone.  The  diagnosis 
must  be  made  from  the  history  and  course  of  the  disease  or  from 
the  presence  of  tubercle  bacilli  in  the  sputa. 

(b)  The  extensive  atelectasis  of  the  lower  lobes  which  may  ac- 
company broncho-pneumonia  gives  rise  to  dulness  and  absence  of 
respiratory  and  vocal  sounds.  Thus,  the  signs  of  pleuritic  effusion 
are  simulated,  and  in  children  the  possibility  of  empyema  should 
not  be  forgotten.  As  a  rule,  broncho-pneumonia  gives  rise  to  much 
greater  dyspnoea,  and  is  associated  with  a  more  extensive  bronchitis, 
than  usually  coexist  with  pleural  effusion.  The  atelectatic  lobules 
may  be  expanded  by  coughing  or  by  the  cutaneous  stimulus  of  cold 
water,  and  thus  resonance  and  breath  sounds  may  suddenly  return. 
With  pleuritic  effusions,  of  course,  such  a  change  is  impossible. 

TUBERCULOSIS  OF  THE  LUNGS. 
(1)  Incipient  Tuberculosis. 

In  the  earlier  stages  of  the  disease  there  may  be  absolutely  no 
recognizable  physical  signs,  and  the  diagnosis  may  be  established 
only  by  the  positive  result  of  a  tuberculin  injection  or  by  the  com- 
bination of  debility  with  slight  fever  not  otherwise  to  be  accounted 
for. 


BRONCHITIS,   PNEUMONIA,    TUBERCULOSIS.  305 

In  some  cases  the  earliest  evidence  of  the  disease  is  haemoptysis.' 
When  a  patient  consults  a  physician  on  account  of  haemoptysis,  it 
is  frequently  impossible  to  find  any  physical  signs  of  disease  in  the 
lungs ;  not  until  weeks  or  months  later  do  the  characteristic  changes 
recognizable  by  physical  examination  make  their  appearance. 

The  very  early  hoarseness  of  the  voice  in  tuberculous  patients  is 
of  great  importance  and  often  attracts  our  attention  to  the  lungs 
when  the  patient  has  said  nothing  about  them.  Definite  physical 
signs  in  the  lungs  and  tubercle  bacilli  in  the  sputa  (artificially  ob- 

Rales.  .. 


FIG.  160.— Diagram  to  Show  Position  of  Earliest  Signs  in  Tuberculosis. 

tained  through  the  use  of  potassic  iodide,  see  below)  may  occasion- 
ally be  demonstrated  before  any  cough  has  appeared.  On  the  other 
hand,  the  patient  may  cough  for  weeks  before  anything  abnormal 
can  be  discovered  in  the  lungs.  Occasionally  tuberculosis  begins 
with  an  ordinarily  bilateral  bronchitis.  I  have  found  tubercle  ba- 
cilli in  four  such  cases.  More  often  the  earliest  physical  signs 
are : 

(a)  Fine  crackling  rales  at  the  apex  of  one  lung,  heard  only 

1  Never  percuss  a  patient  within  forty-eight  hours  after  a  hemorrhage,  and 
never  encourage  cough  or  forced  respiration  in  such  a  one.  There  is  danger 
of  starting  a  fresh  hemorrhage. 

20 


306  PHYSICAL  DIAGNOSIS. 

with  or  after  cough  and  at  the  end  of  inspiration.  [More  rarely 
squeaks  may  be  heard.]  (See  Fig.  160). 

(£>)  A  slight  diminution  in  the  excursion  of  the  diaphragm  on 
the  affected  side,  as  shown  by  Litten's  diaphragm  shadow. 

(c)  Slight  diminution  in  the  intensity  of  the  respiratory  mur- 
mur, with  or  without  interrupted  inspiration  ("cog-wheel  breath- 
ing"). 

(a)  In  examining  the  apices  of  the  lungs  for  evidence  of  early 
tuberculosis  one  should  secure  if  possible  perfect  quiet  in  the  room, 
and  have  the  clothes  entirely  removed  from  the  patient's  chest. 
The  ordinary  hard-rubber  chest-piece  is  better  than  the  chest-piece 
of  the  Bowles  instrument,  and  both  the  chest  and  the  skin  should 
be  wetted.  After  listening  during  quiet  breathing  over  the  apices 
above  and  below  the  clavicle  in  front,  and  above  the  spine  of 
the  scapula  behind,  the  patient  should  be  directed  to  breathe  out 
and  then,  at  the  end  of  expiration,  to  cough.  During  the  dee]) 
inspiration  which  is  likely  to  precede  or  to  follow  such  a  cough  one 
should  listen  as  carefully  as  possible  at  the  apex  of  the  lung,  above 
and  below  the  clavicle,  concentrating  attention  especially  upon  the 
last  quarter  of  the  inspiration,  when  rales  are  most  apt  to  appear. 
Sometimes  only  one  or  two  crackles  may  be  heard  with  each  inspi- 
ration, and  not  infrequently  they  will  not  be  heard  at  all  unless  the 
patient  is  made  to  cough,  but  even  a  single  rale,  if  persistent,*  is 
important.  In  children  who  cannot  cough  at  will,  one  can  accom- 
plish nearly  the  same  result  by  making  them  count  as  long  as  pos- 
sible with  one  breath  and  then  listening  to  the  immediately  suc- 
ceeding inspiration.  When  listening  over  the  apex  of  the  lung, 
one  should  never  allow  the  patient  to  turn  his  head  sharply  in  the 
other  direction,  since  such  an  attitude  stretches  the  skin  and  mus- 
cles on  the  side  on  which  we  are  listening  so  as  to  produce  annoy- 
ing muscle  sounds  or  skin  rubs. 

In  cases  hi  which  one  suspects  that  incipient  tuberculosis  is 

1  Rilles  heard  only  during  the  first  few  breaths  and  not  found  to  persist  on 
subsequent  examinations,  may  be  due  to  the  expansion  of  atelectatic  lobules 


BRONCHITIS,  PNEUMONIA,    TUBERCULOSIS.  307 

present  and  yet  in  which  no  positive  evidence  can  be  found,  it  is  a 
good  plan  to  give  iddide  of  potassium  (gr.  vii.  three  times  a  day)  for 
a  few  days.  The  effect  of  this  drug  is  often  to  make  rales  more 
distinct,  and  sometimes  to  increase  expectoration  so  that  tubercle 
bacilli  can  be  demonstrated  when  before  none  were  to  be  obtained. ' 

(&)  The  diminution  in  the  excursion  of  the  diaphragm  upon  the 
affected  side  in  cases  of  incipient  phthisis  has  been  much  insisted 
upon  by  F.  H.  Williams  and  others  who  have  interested  themselves 
in  the  radioscopy  of  the  chest.  Litten's  diaphragm  shadow  gives 
us  a  method  of  observing  the  same  phenomenon  without  the  need 
of  a  fluoroscope.  Even  very  slight  tuberculous  changes  in  the  lung 
are  sufficient  to  diminish  its  elasticity  and  so  to  restrict  its  excur- 
sion and  that  of  the  diaphragm.  Comparisons  must  always  be 
made  with  the  sound  side  in  such  cases,  as  individuals  differ  very 
much  in  the  extent  with  which  they  are  capable  of  depressing  the 
diaphragm.  It  must  be  remembered  that  pleuritic  adhesions,  due 
to  a  previous  inflammation  of  the  pleura,  may  diminish  or  alto- 
gether abolish  the  excursion  of  the  diaphragm  shadow,  independ- 
ently of  any  active  disease  in  the  lung  itself. 

Those  who  are  expert  in  the  use  of  the  fluoroscope  believe  that 
they  can  detect  the  presence  of  tuberculosis  in  the  lung  by  radi- 
oscopy at  a  period  at  which  no  other  method  of  physical  examina- 
tion shows  anything  abnormal.  I  shall  return  to  the  consideration 
of  this  point  in  the  section  on  Radioscopy.2 

Interrupted  or  coy-wheel  respiration,  in  which  the  inspiration 
comes  in  high-pitched  jerky  puffs,  signifies  that  the  entrance  of  the 
air  into  the  alveoli  is  impeded,  and  such  impediment  is  most  likely 
to  be  due  to  tuberculosis  when  present  over  a  considerable  period 
in  a  localized  area  of  pulmonary  tissue. 

1  Any  irritating  vapor — for  example,  creosote  vapor — which  produces  vio- 
lent cough  and  expectoration,  may  be  used  to  expel  bronchial  secretions  in 
doubtful  cases.  Tubercle  bacilli  may  then  be  found  in  the  sputum  of  patients 
who,  without  the  irritating  inhalation,  have  no  cough  and  so  no  sputa. 

4  See  Appendix  C. 


308 


PHYSICAL  DIAGNOSIS. 


(2)  Moderately  Advanced  Cas$s 

So  far  I  have  been  speaking  of  the  detection  of  tuberculosis  at 
a  stage  prior  to  the  production  of  any  considerable  amount  of  solid- 
ification The  signs  considered  have  been  those  of  bronchitis 
localized  at  the  apex  of  the  lung,  or  of  a  slightly  diminished  pul- 
monary elasticity,  whether  due  to  pleuritic  adhesions  or  to  other 
causes.  We  have  next  to  consider  the  signs  in  cases  in  which  so- 
lidification is  present,  though  relatively  slight  in  amount  This 
condition  is  comparatively  easy  to  recognize  when  it  occurs  at  the 


Riles. -___ 


-    Complete 
solidiflcation. 


Partial 
"""  solidification. 


, 4—  Rales. 


FIG.  161.— Diagram  of  Signs  in  Phthisis. 

left  apex,  but  more  difficult  in  case  only  the  right  apex  is  diseased 
Partial  solidification  of  a  small  area  of  lung  tissue  at  the  left  apex 
gives  rise  to 

(a)  Slight  dulness  on  light  percussion,1  with  increased  resist- 
ance. 

(b)  Slight  increase  in  the  intensity  of  the  spoken  and  whispered 
voice,  and  of  the  tactile  fremitus  (hi  many  cases) 

i  Other  causes  of  dulness,  such  as  asymmetry  of  the  chest,  pleural  thicken- 
ing, and  tumors,  must  be  excluded.  Emphysema  of  the  lobules  surrounding 
the  tuberculous  patch  may  completely  mask  the  dulness. 


BRONCHITIS,   PNEUMONIA,   TUBERCULOSIS.  309 

(c)  Some  one  of  the  numerous  varieties  of  broncho-vesicular 
breathing  (true  bronchial  breathing  is  a  late  sign). 

(d)  Abnormally  loud  transmission  of  the   heart  sounds,  espe- 
cially under  the  clavicle. 

(e)  Cardio-respiratory  murmurs   (vide  p.  197    are  occasionally 
due  to  the  pressure  of  a  tuberculous  lobule  upon  the  subclavian 
artery.     In  connection  with  other  signs  they  are  not  altogether 
valueless  in  diagnosis 

In  case  there  is  also  a  certain  amount  of  secretion  in  the  bron- 
chi of  the  affected  area  or  ulceration  around  them,  one  often  hears 
rales  of  a  peculiar  quality  to  which  Skoda  has  given  the  name  of 
"consonating  rales."  Rales  produced  in  or  very  near  a  solidified 
area  are  apt  to  have  a  very  sharp,  crackling  quality,  their  intensity 
being  increased  by  the  same  acoustical  conditions  which  increase 
the  intensity  of  the  voice  sounds  over  the  same  area.  When  such 
rales  are  present  at  the  apex  of  either  lung,  the  diagnosis  of  tuber- 
culosis is  almost  certain,  but  if,  as  not  infrequently  occurs,  there 
are  no  rales  to  be  heard  over  the  suspected  area,  our  diagnosis  is 
clear  only  in  case  the  signs  occur  at  the  left  apex.  Precisely  the 
same  signs,  if  present  at  the  right  apex,  leave  us  in  doubt  regard- 
ing the  diagnosis,  for  the  reason  that,  as  has  been  explained  above, 
we  find  at  the  apex  of  the  right  lung  in  health  signs  almost  exactly 
identical  with  those  of  a  slight  degree  of  solidification.  Hence,  if 
these  signs,  and  only  these,  are  discovered  at  the  right  apex,  we 
cannot  feel  sure  about  the  diagnosis  until  it  is  confirmed  by  the 
appearance  of  rales,  the  presence  of  fever,  loss  of  weight,  a  positive 
tuberculin  reaction  (ocular,  cutaneous,  or  subcutaneous),  or  by  the 
finding  of  tubercle  bacilli  in  the  sputum.1 

A  sign  characteristic  of  early  tuberculous  changes  in  the  lung 
and  one  which  I  have  frequently  observed  in  the  lower  and  relatively 
sounder  lobes  of  tuberculous  lungs  is  a  raising  of  the  pitch  of  inspi- 
ration,3 without  any  other  change  in  the  quality  of  the  breathing  cr 
any  other  physical  signs.  The  importance  of  this  sign  in  the  diag- 

1  The  natural  disparity  between  the  two  apices  is  leas  marked  in  thesupra- 
spinous  fossa  behind  than  over  the  clavicle  in  front,  and  hence  pathological 
dulness  at  the  apex  is  more  often  demonstrable  behind  than  in  front. 

2  "Sharp  breathing"  (Turban). 


310 


PHYSICAL  DIAGNOSIS. 


nosis  of  early  tuberculosis  of  the  lungs  was  insisted  upon  by  the 
eider  Flint  in  his  work  on  "The  Eespiratory  Organs"  (1866),  and 
has  more  recently  been  mentioned  by  Norman  Bridge. 

It  must  never  be  forgotten  that  tuberculosis  may  take  root  in 


FIG.  182.— This  Patient  has  Solidification  at  both  Apices  and  Tubercle  Bacilli  in  the  Sputa.    He 

feels  perfectly  well. 


the  most  finely  formed  chests  and  in  persons  apparently  in  blooming 
health.  The  "phthisical  chest  "  and  the  sallow,  emaciated  figure  of 
the  classical  descriptions  apply  only  to  very  advanced  cases.  Fig. 
162  represents  a  patient  with  moderately  advanced  signs  of  phthisis 
and  abundant  tubercle  bacilli  in  the  sputa.  He  feels  perfectly 


BRONCHITIS,  PNEUMONIA,   TUBERCULOSIS.  311 

well  and  is  at  work.     On  the  other  hand,  a  patient  with  very  slight 
signs  may  be  utterly  prostrated  by  the  toxaemia  of  the  disease. 

(3)  Advanced  Phthisis. 

Characteristic  of  the  more  advance  dotages  of  tuberculosis  in  the 
lungs  is  the  existence  of  large  areas  of  solidified  and  retracted  lung, 
and,  to  a  lesser  extent,  the  signs  of  cavity  formation.  The  patients 
are  pale,  emaciated,  and  feverish.  The  signs  of  solidification  have 
already  been  enumerated  in  speaking  of  pneumonia.  They  are : 

1.  Marked  dulness,  or  even  flatness,1  with  increased  sense  of  re- 
sistance. 

2.  Great  increase  of  voice  sounds  or  of  tactile  fremitus. 

3.  Tubular  breathing,  sometimes  loud,  sometimes  feeble. 

4.  As  a  rule,  coarse  rales,  due  to  breaking  down  of  the  caseous 
tissue,  are  also  to  be  heard  over  the  solidified  areas.     Sometimes 
these  rales  are  produced  within  the  pleuritic  adhesions,  which  are 
almost  invariably  present  in  such  cases.     If  they  disappear  just 
after  profuse  expectoration,  one  may  infer  that  they  are  produced 
within  the  lung. 

Increase  in  the  intensity  of  the  spoken  voice,  of  the  whispered 
voice,  or  of  the  tactile  fremitus  may  be  marked  and  yet  no'  tubular 
breathing  be  audible.  Each  of  these  signs  may  exist  and  be  of  im- 
portance as  signs  of  solidification  without  the  others.  As  a  rule, 
it  is  true,  they  are  associated  and  form  a  very  characteristic  group, 
but  there  are  many  exceptions  to  this  rule. 

The  tendency  of  the  spinal  column  to  transmit  to  the  sound 
lung  sounds  produced  in  an  area  of  solidification  immediately 
adjacent  to  it  on  the  other  side,  has  been  already  alluded  to  in 
the  section  on  pneumonia,  and  what  was  then  said  holds  good  of  tu- 
berculous solidification.  Owing  to  this  it  is  easy  to  be  misled  into 
diagnosing  solidification  at  both  apices  when  only  one  is  affected. 

Since  solidification  is  usually  accompanied  by  retraction  in  the 
affected  lung  in  very  advanced  cases,  the  chest  falls  in  to  a  greater 

1  Unless  senile  emphysema  masks  it.  Fibroid  phthisis  (vide  infra)  may 
show  no  dulness.  Remember  that  gastric  tympany  may  be  transmitted  to  the 
left  lung  and  mask  dulness  there. 


312 


PHYSICAL  DIAGNOSIS. 


or  less  extent  over  the  affected  area,  and  the  respiratory  excursion 
is  much  diminished,  as  shown  by  ordinary  inspection  and  by  the 
diminution  or  disappearance  of  the  excursion  of  the  diaphragm 
shadow.  The  intensity  of  the  tubular  breathing  depends  on  the 
proximity  of  the  solidified  portions  to  the  chest  wall  and  to  the 
large  bronchi,  as  well  as  on  the  presence  or  absence  of  pleuritic 
thickening. 

It  is  rare  to  find  a  whole  lung  solidified.     The  process,  begin- 
ning at  the  apex  or  just  below,  extends  down  as  far  as  the  fourth 


Bronchinl  breath- 
ing, dulness. 

Increased  fremitus. 

Increased  voice 
sounds. 


Rales. 


.-  Kales. 


FIG.  163.— To  Illustrate  Progress  of  Signs  in  Pulmonary  Tuberculosis. 

rib  in  iront,  i.e.,  through  the  upper  lobe,  in  a  relatively  short  time, 
but  below  that  point  its  progress  is  comparatively  slow  and  the 
lower  lobes  may  be  but  little  affected  up  to  the  time  of  death.  On 
the  relatively  sound  side  the  exaggerated  (compensatory)  resonance 
may  mask  the  dulness  of  a  beginning  solidification  there,  which 
sooner  or  later  is  almost  sure  to  occur.  It  is  exceedingly  rare  for 
the  disease  to  extend  far  in  one  lung  without  involving  the  other. 

About  the  time  that  the  tuberculous  process  invades  the  previ- 
ously sound  lung  it  is  apt  to  show  itself  at  the  apex  of  the  lower  lobe 


BRONCHITIS,   PNEUMONIA,    TUBERCULOSIS.  313 

of  the  lung  first  affected.  Consonating  rales  appear  posteriorly  along 
the  line  which  the  vertebral  border  of  the  scapula  makes  when  the 
arm  is  raised  over  the  shoulder.  These  points  are  illustrated  in 
Fig.  163. 

Cavity  Formation. 

Cavities  of  greater  or  lesser  extent  are  formed  in  almost  every 
case  of  advanced  phthisis,  but  very  seldom  do  they  attain  such  size 
as  to  be  recognizable  during  life.  Indeed,  the  diagnosis  of  cavity 
in  phthisis  plays  a  much  larger  part  in  the  text-books  than  it  does 
in  the  practice  of  medicine,  since  to  be  recognizable  by  physical 
examination  a  cavity  must  not  only  be  of  considerable  size  but  its 
walls  must  be  rigid  and  not  subject  to  collapse,1  it  must  communi- 
cate directly  with  the  bronchus  and  be  situated  near  the  surface  of 
the  lung,  and  it  must  not  be  filled  up  with  secretions.  It  can  read- 
ily be  appreciated  that  it  is  but  seldom  that  all  these  conditions  are 
present  at  once ;  even  then  the  diagnosis  of  cavity  is  a  difficult  one, 
and  I  have  often  known  skilled  observers  to  be  mistaken  on  this 
point. 

The  signs  upon  which  most  reliance  is  usually  placed  are : 

(a)  Amphoric  or  cavernous  breathing. 

(b)  "  Cracked-pot  resonance  "  on  percussion. 

(c)  Coarse,  gurgling  rales. 

(a)  Cavernous  or  Amphoric  Respiration.  —  When  present,  this 
type  of  breathing  is  almost  pathognomoriic  of  a  cavity.  It  is  also 
to  be  heard  in  pneumothorax,  but  the  latter  disease  can  usually 
be  distinguished  by  the  associated  physical  signs.  Cavernous 
breathing  differs  from  bronchial  or  tubular  breathing  in  that  its 
pitch  is  lower  and  its  quality  hollow.  The  pitch  of  expiration 
is  even  lower  than  that  of  inspiration.  Since  a  pulmonary  cavity 
is  almost  always  surrounded  by  a  layer  of  solidified  lung  tissue,  we 
usually  hear  around  the  area  occupied  by  the  cavity  a  ring  of  bron- 
chial breathing  with  which  we  can  compare  the  quality  of  the  cav- 
ernous sounds. 

1  Yet  not  so  rigid  as  to  be  uninfluenced  by  the  entrance  and  exit  of  air. 


314  PHYSICAL  DIAGNOSIS. 

(£)  Percussion  sometimes  enables  us  to  demonstrate  a  circum- 
scribed area  of  tympanitic  resonance  surrounded  by  marked  dul- 
ness.  More  often  the  "  cracked-pot  "  resonance  can  be  elicited  by 
percussing  over  the  suspected  area  while  the  chest-piece  of  the 
stethoscope  is  held  close  to  the  patient's  open  mouth. 

Cracked-pot  resonance  is  often  absent  over  cavities ;  rarely  oc- 
curs in  any  other  condition  (e.ff.f  in  percussing  the  chest  of  a 
healthy,  crying  baby,  and  occasionally  over  solidified  lung). 

(c)  The  voice  sounds  sometimes  have  a  peculiar  hollow  quality 
(amphoric  voice  and  whisper). 

(d)  Cough  or  the  movements  of  respiration  may  bring  out  over 
the  suspected  area  splashing  or  gurgling  sounds,  or  occasionally 
a  metallic  tinkle.     Flint  has  also  observed  a  circumscribed  bulging 
of  an  interspace  during  cough.     Bruce  noted  a  high-pitched  suck- 
ing sound  during  the  inspiration  following  a  hard  cough  ("rubber- 
ball  sound"). 

Very  important  in  the  diagnosis  of  cavity  is  the  intermittence  of 
all  above-mentioned  signs,  which  are  present  only  when  the  cavity 
is  comparatively  empty,  and  disappear  when  it  becomes  wholly  or 
mostly  filled  with  secretions.  For  this  reason,  the  signs  are  very 
apt  to  be  absent  in  the  early  morning  before  the  patient  has  expelled 
the  accumulated  secretions  by  coughing. 

Wintrich  noticed  that  the  note  obtained  when  percussing  over 
a  pulmonary  cavity  may  change  its  pitch  if  the  patient  opens  his 
mouth.  Gerhardt  observed  that  the  note  obtained  over  a  pulmo- 
nary cavity  changes  if  the  patient  shifts  from  an  upright  to  a  re- 
cumbent position.  Neither  of  these  points,  however,  is  of  much 
importance  in  diagnosis.  The  same  is  true  of  metamorphosing 
breathing  (see  above,  p.  156). 

Tuberculous  cavities  differ  from  those  produced  by  pulmonary 
abscess  or  gangrene  in  that  the  latter  are  usually  situated  in  the 
lower  two-thirds  of  the  lung.  Bronchiectasis,  if  considerable  in 
extent,  cannot  be  distinguished  by  physical  signs  alone  from  a 
tuberculous  cavity. 


BRONCHITIS,   PXEDIONIA,    TUBERCULOSIS.  315 

Fibroid  Phthisis. 

This  term  applies  to  slow  tuberculous  processes  with  relatively 
little  uleeration  and  much  fibrous  thickening. 

In  a  considerable  number  of  cases  the  physical  signs  do  not 
differ  materially  from  those  of  the  ordinary  ulcerating  forms  of 
the  disease,  but  occasionally  when  a  slow  chronic  process  at  the 
apex  of  the  lung  results  in  the  falling-away  of  the  parenchyma  of 
the  lung  so  that  we  have  left  a  cluster  of  bronchi  matted  together 
by  fibrous  tissue,  the  percussion  note  may  be  noticeably  tympani- 
tic;  similar  tympany  may  be  due  to  emphysema  of  the  lobules 
surrounding  the  diseased  portion.  In  such  cases  rales  are  usu- 
ally entirely  absent ;  otherwise,  the  signs  do  not  differ  from  those 
of  ordinary  phthisis,  except  that  falling-in  of  the  chest  walls  over 
the  retracted  lung  may  be  more  marked.  Occasionally  the  heart 
may  be  drawn  toward  the  affected  lobes,  e.g.,  upward  and  to  the 
right  in  right-sided  phthisis  at  the  apex.  In  two  cases  of  fibroid 
disease  at  the  left  base,  Flint  found  the  heart  beating  near  the 
lower  angle  of  the  left  scapula. 

Phthisis  ir it/i  Predominant  Pleural  Thickening. 

Tuberculosis  in  the  lung  is  in  certain  cases  overshadowed  by  the 
manifestations  of  the  same  disease  in  the  pleura,  so  that  the  signs 
are  chiefly  those  of  thickened  pleura.  To  this  subject  I  shall  return 
in  the  section  of  Diseases  on  the  Pleura  (see  below,  p.  331). 

Emphysematous  Form  of  Phthisis. 

Tubercle  bacilli  are  not  very  infrequently  found  in  the  sputa  of 
cases  in  which  the  history  and  physical  signs  point  to  chronic  bron- 
chitis with  emphysema.  I  have  seen  two  such  cases  within  a  year 
Dulness  is  wholly  masked  by  emphysema,  tubular  breathing  is 
absent,  and  piping  and  babbling  rales  are  scattered  throughout  both 
lungs.  The  emphysema  may  be  of  the  senile  or  small-lunged  type, 
as  in  one  of  my  recent  cases  (with  autopsy),  or  it  may  be  associ- 
ated with  huge  downy  kings  and  the  "barrel  chest."  Such  cases 


316  PHYSICAL  DIAGNOSIS. 

cannot  be  identified  as  phthisis  during  life  unless  we  make  it  an 
invariable  rule  to  examine  for  tubercle  bacilli  the  sputa  of  every 
case  in  which  sputa  can  be  obtained,  no  matter  what  are  the  physi- 
cal signs. 

Phthisis  with  Anomalous  Distribution  of  the  Lesions. 

Very  rarely  a  tuberculous  process  may  begin  at  the  base  of  the 
lung  When  the  process  seems  to  begin  in  this  way,  a  healed  focus 
is  often  to  be  found  at  one  apex  surrounded  by  a  shell  of  healthy 
lung. 

The  summit  of  the  axilla  should  always  be  carefully  examined, 
as  tuberculous  foci  may  be  so  situated  as  to  produce  signs  only  at 
that  point. 

Another  point  often  overlooked  in  physical  examination  is  the 
linyula  pulmonalis  or  tongue-like  projection  from  the  anterior  mar- 
gin of  the  left  lung  overlapping  the  heart.  Tuberculosis  is  some- 
times found  further  advanced  at  this  point  than  anywhere  else. 

As  a  rule  cases  in  which  signs  like  those  of  phthisis  are  found 
at  the  base  of  the  lung  turn  out  to  be  either  empyema,  or  abscess, 
or  unresolved  pneumonia  (cirrhosis  of  the  lung). 

Acute  Pulmonary  Tuberculosis. 

No  one  of  the  three  forms  in  which  acute  phthisis  occurs,  viz., 

(a)  Acute  tuberculous  pneumonia, 

(£>)  Acute  tuberculous  bronchitis  and  peribronchitis, 

(c)  Acute  miliary  tuberculosis,  involving  the  lungs,  can  be  rec- 
ognized by  physical  examination  of  the  chest.  The  first  form  is 
almost  invariably  mistaken  for  ordinary  croupous  pneumonia,  until 
the  examination  of  the  sputa  establishes  the  correct  diagnosis.  In 
the  other  two  forms  of  the  disease,  the  physical  signs  are  simpiy 
those  of  general  bronchitis. 


CHAPTER   XV. 

EMPHYSEMA,    ASTHMA,    PULMONARY   SYPHILIS,  ETC. 

X 

I.  EMPHYSEMA. 

FOR  clinical  purposes,  the  great  majority  of  cases  of  emphy- 
sema may  be  divided  into  two  groups. 

(1)  Large-lunged  emphysema,  usually  associated  with  chronic 
bronchitis  and  asthma. 

(2)  Small-lunged,  or  senile,  emphysema. 

Although  the  second  of  these  forms  is  exceedingly  common,  it 
is  so  much  less  likely  than  the  first  form  to  give  rise  to  distressing 
symptoms  that  it  is  chiefly  the  large-lunged  emphysema  which  is 
seen  by  the  physician.  In  both  conditions  we  have  a  dilatation 
and  finally  a  breaking  down  of  the  alveolar  walls  until  the  air  spaces 
are  become  relatively  large  and  inelastic.  In  both  forms,  the  elas- 
ticity of  the  lung  is  diminished ;  but  in  the  large-lunged  form  we 
have  an  increase  in  the  volume  of  the  whole  organ  in  addition  to 
the  changes  just  mentioned. 

Large-Lunged  Emphysema. 

The  diagnosis  can  usually  be  made  by  inspection  alone.  In 
typical  cases  the  antero-posterior  diameter  of  the  chest  is  greatly 
increased,  the  in-spaces  are  widened,  and  the  costal  angle  is  blunted, 
while  the  angle  of  Ludwig1  becomes  prominent.  The  shoulders  are 
high  and  stooping  and  the  neck  is  short  (see  Fig.  164).  The  patient 
is  often  considerably  cyanosed,  and  his  breathing  rapid  and  difficult. 
Inspiration  is  short  and  harsh ;  expiration  prolonged  and  difficult. 
The  ribs  move  but  little,  and,  owing  to  the  ossification  of  their  car- 

1  Formed  by  the  junction  of  the  manubrium  with  the  second  piece  of  the 
sternum. 


318 


PHYSICAL  DIAGNOSIS. 


tilages,  are  apt  to  rise  and  fall  as  if  made  in  one  piece  (en  cui- 
rasse).  The  working  of  the  auxiliary  muscles  of  respiration  is  not 
infrequently  seen.  The  diaphragm  shadow  (Litten's  sign)  begins 
its  excursion  one  or  two  ribs  farther  down  than  usual  and  moves  a 
much  shorter  distance  than  in  normal  cases. 

Palpation  shows  a  diminution  in  the  tactile  fremitus,  through- 
out the  affected  portions ;  that  is,  usually  throughout  the  whole  of 
both  lungs.  Sometimes  it  is 
scarcely  to  be  perceived  at  all. 

Percussion  yields  very  in- 
teresting information.  The 
disease  manifests  itself — 

(a)  By  hyper-resonance   on 
percussion,   with   a    shade    of 
tympanitic  quality  in  the  note. 

(b)  By  the  extension  of  the 
margins   of    the  lung  so  that 
they  encroach  upon  portions  of 
the  chest  not  ordinarily  reso- 
nant. 

The  degree  of  hyper-reso- 
nance depends  not  only  upon 
the  degree  of  emphysema  but 
upon  the  thickness  of  the  chest 

walls.  The  note  is  most  resonant  and  has  most  of  the  tympanitic 
quality  when  the  disease  occurs  in  old  persons  with  relatively  thin 
chest  walls.  The  encroachment  of  the  over-voluminous  lungs  upon 
the  liver  and  heart  is  demonstrated  by  the  lowering  of  the  line  of 
liver  flatness  from  its  ordinary  position  at  the  sixth  rib  to  a  point 
one  or  two  interspaces  farther  down  or  even  to  the  costal  margin, 
while  the  area  of  cardiac  dulness  may  be  altogether  obliterated, 
the  lungs  completely  closing  over  the  surface  of  the  heart.  At  the 
apices  of  the  lungs  resonance  may  be  obtained  one  or  two  centi- 
metres higher  than  normally  and  the  quality  may  be  markedly  tym- 
panitic. In  the  axillae  and  in  the  back  the  pulmonary  resonance 
extends  down  one  inch  or  more  below  its  normal  position. 


FIG.  164.— Barrel  Chest  due  to  Chronic  iiiou- 
chilis  and  Emphysema. 


EMPHYSEMA,  ASTHMA,   PULMONARY  SYPHILIS,  ETC.    319 

Auscultation  shows  in  uncomplicated  cases  no  very  marked  mod- 
ification of  the  inspiratory  murmur,  which,  however,  may  be  short- 
ened and  enfeebled.  The  most  striking  change  is  a  great  prolonga- 
tion and  enfeeblement  of  expiration,  with  a  lowering  of  its  pitch 
(see  Fig.  165). 

This  type  of  breathing  is  like  bronchial  breathing  in  one  re- 
spect ;  namely,  that  in  both  of  them  expiration  is  made  prolonged, 
but  emphysematous  breathing  is  feeble  and  low- 
pitched,  while  bronchial  breathing  is  intense 
and  high-pitched.  At  the  bases  of  the  lungs 
the  respiration  is  especially  feeble  and  may  be 
altogether  replaced  by  crackling  rales. 

In    "small-lunged    emphysema"  we    have 

precisely  the  same  physical  signs,  except  that 
FIG.  165.— Diagram  to  ,,,,.,.,,,  -,  -, 

illustrate    Emphyse-     the  boundaries   o±  the  lung  are  not  extended, 

ma  to  us    Breathing     expiration  is  less  prolonged  and  less  difficult, 

with  Musical  Expira-  %    .         .      ,.         .  T,     . 

tory  Rales.  and  inspiration  is  normal.      It  does  not  tend 

to  be  complicated  by  bronchitis  and  asthma; 
indeed  the  small-lunged  emphysema  rarely  gives  rise  to  any  symp- 
toms, and  is  discovered  as  a  matter  of  routine  physical  examination. 

Summary. 

1.  Hyper-resonance  on  percussion. 

2.  Feeble  breathing  with  prolonged  expiration. 

3.  Diminished  fremitus  and  voice  sounds. 

4.  Encroachment  of  the  resonant  lungs  on  the  heart  and  liver 
dulness  (in  the  large-lunged  form). 

Differential  Diagnosis. 

(a)  Emphysema  may  be  confounded  with  pneumothorax,  since  in 
both  conditions  hyper-resonance  and  feeble  breathing  are  present. 
But  emphysema  is  usually  bilateral,  encroaches  upon  but  does  not 
displace  neighboring  organs,  and  is  not  often  associated  with  hydro- 
thorax.  Emphysema,  if  extensive,  is  usually  associated  with 
chronic  bronchitis  and  so  with  squeaking  or  bubbling  rales,  while  in 


320  PHYSICAL  DIAGNOSIS. 

pneumothorax  breathing  is  absent   or   distant   amphoric  without 
rales. 

(£)  The  signs  of  aneurism  of  the  aorta  pressing  on  the  trachea 
or  on  a  primary  bronchus  are  sometimes  overlooked  because  the  fore- 
ground of  the  clinical  picture  is  occupied  by  the  signs  of  a  coexist- 
ing bronchitis  with  emphysema.  The  cough  and  wheezing  which 
the  presence  of  the  aneurism  produces  may  then  be  accounted  for 
as  part  of  the  long-standing  bronchitis,  and  the  dulness  and  thrill 
over  the  upper  sternum  to  .which  the  aneurism  naturally  gives  rise 
may  be  masked  by  extension  of  lung  borders.  But  the  evidence  of 
pressure  on  mediastinal  nerves  and  vessels  (aphonia,  unequal  pulses 
or  pupils,  etc.),  and  the  presence  of  a  diastolic  shock  and  tracheal 
tug  are  usually  demonstrable ; '  the  danger  is  that  we  shall  forget  to 
look  for  them. 

(c)  Uncompensated  mitral  stenosis  may  produce    dyspnoea  and 
cyanosis  and  weak  rapid  heart  action  somewhat  similar  to  that  seen 
in  emphysema,  and  may  not  be  associated  with  any  cardiac  mur- 
mur, but  the  dyspnoea  is  not  of  the  expiratory  type,  and  the  irregu- 
larity of  the  heart,  with  evidence  of  dropsy  and  general  venous 
stasis,  should  make  it  evident  that  something  more  than  simple  em 
physema  is  present. 

(d)  The  occurrence  of  an  emphysematous  form  of  phthisis  I 
have  already  mentioned  in  discussing  the  latter  disease  (see  p.  304). 

Emphysema  with  Bronchitis  or  Asthma. 

In  the  great  majority  of  cases,  emphysema  of  the  lungs  is  asso- 
ciated with  chronic  bronchitis,  bronchieotasis,  and  asthmatic  parox- 
ysms. Such  association  is  especially  frequent  in  elderly  men  who 
have  had  a  winter  cough  for  many  years  and  in  whom  arterio-scle- 
rosis  is  more  or  less  well  marked.  In  such  cases  the  prolonged  and 
feeble  expiration  is  usually  accompanied  by  squeaking  and  groaning 
sounds,  or  by  moist  rales  of  various  sizes  and  in  various  parts  of 
the  chest.  When  the  asthmatic  element  predominates,  dry  rales 
are  more  noticeable,  and  occur  chiefly  or  wholly  during  expiration, 
while  inspiration  is  reduced  to  a  short,  quick  gasp. 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.     321 

Interstitial  Emphysema. 

In  rare  cases  violent  paroxysms  of  coughing  may  rupture  the 
walls  of  the  alveoli  so  as  to  allow  the  passage  of  air  into  the  inter- 
stitial tissue  of  the  lung,  from  whence  it  may  work  through  and 
manifest  itself  under  the  skin,  giving  rise  to  a  peculiar  crackling 
sensation  on  palpation,  and  to  a  similar  sound  on  auscultation. 
More  frequently  the  trouble  arises  in  connection  with  a  tracheot- 
omy wound,  the  air  penetrating  under  the  skin  and  producing  a 
downy,  crepitating  swelling. 

"  Complementary  Emphysema." 

When  extra  work  is  thrown  upon  one  lung  by  loss  of  the  func- 
tion of  the  other,  as  in  pleuritic  effusion — a  considerable  stretching 
of  the  overworked  sound  lung  may  take  place.  The  elasticity  of 
the  lung  is  not  diminished  as  in  emphysema,  but  is  greatly  in- 
creased. Hence  the  term  complementary  emphysema  should  be 
dropped  and  the  term  complementary  (or  compensatory)  hyper- 
resonance  substituted. 

Like  emphysema,  this  condition  leads  to  hyper-resonance  on  per- 
cussion and  to  encroachment  of  the  pulmonary  margins  upon  the 
neighboring  organs  (as  shown  by  a  reduction  in  the  area  of  dulness 
corresponding  to  them),  but  the  respiratory  murmur  is  exaggerated 
and  has  none  of  the  characteristics  of  emphysematous  breathing. 

A  word  may  here  be  added  regarding  the  condition  described 
by  West  under  the  name  of 

Acute  Pulmonary  Tympanites. 

In  fevers  and  other  acute  debilitating  conditions  West  has  ob- 
served that  the  lungs  may  become  hyper-resonant  and  somewhat 
tympanitic  on  percussion,  owing,  he  believes,  to  a  loss  of  pulmo- 
nary elasticity.  The  tympanitic  note,  often  observable  around  the 
solidified  tissue  in  pneumonia,  is  to  be  accounted  for,  he  believes, 
in  the  same  way.  Like  the  shortening  of  the  first  heart  sound, 
acute  pulmonary  tympanites  points  to  the  weakening  of  muscle  fibre 
which  toxaemia  is  so  apt  to  produce.  Apparently  the  muscle  fibres 
of  the  lung  suffer  like  those  of  the  heart. 
21 


322  PHYSICAL  DIAGNOSIS, 

BRONCHIAL  ASTHMA. 

(PRIMARY  SPASM  OF  THE  BRONCHI). 

During  a  paroxysm  of  bronchial  asthma  our  attention  is  at- 
tracted even  at  a  distance  by  the  loud,  wheezing,  prolonged  expira 
tion  preceded  by  an  abortive  gasping  inspiration.  The  breathing 
is  labored,  much  quickened  in  rate,  and  cyanosis  is  very  marked. 
The  chest  is  distended  and  hyper-resonant,  the  position  of  the  dia- 
phragm low  and  its  excursion  much  limited,  and  the  cardiac  and 
hepatic  dulness  obliterated  by  the  resonance  of  the  distended  lungs. 
On  auscultation,  practically  no  respiratory  murmur  is  to  be  heard 
despite  the  violent  plunging  of  the  chest  walls.  We  hear  squeaks, 
groans,  muscular  rumbles,  and  a  variety  of  strange  sounds,  but 
amid  them  all  practically  nothing  is  to  be  heard  of  the  breath 
sounds.  "  The  asthmatic  storm  flits  about  the  chest,  now  here  now 
there,"  the  rales  appearing  and  disappearing. 

At  the  extreme  base  of  the  lungs  there  may  be  dulness  due  to 
atelectasis  of  the  thin  pulmonary  margins. 

Differential  Diagnosis. 

(a)  Mechanical  irritation  of  the  bronchi,  as  by  the  pressure  of 
an  aneurism  or  enlarged  gland,  may  set  up  a  spasm  of  the  neigh- 
boring  bronchioles   much   resembling   that  of  primary  bronchial 
asthma,  but  thorough  examination  should   reveal  other  evidence 
of  mediastinal  pressure,  and  the  history  of  the  case  is  very  different 
from  that  of  asthma. 

(b)  Spasm  of  the  glottis  produces  a  noisy  dyspnoea,  but  the  diffi- 
culty is  with  inspiration,  instead  of  with  expiration,  and  the  crow- 
ing or  barking  sound  is  not  like  the  long  wheeze  of  asthma.     No 
rales  are  to  be  heard,  and  the  signs  in  the  lungs  are  those  of  col- 
lapse instead  of  the  distention  characteristic  of  asthma. 

(c)  The  paroxysmal  attacks  of  dyspnoea,  which  often  occur  in 
chronic  nephritis,  myocarditis,  and  other  diseases  of  the  heart  and  kid- 
ney, may  be  entirely  indistinguishable  from  primary  bronchial  asth- 
ma but  for  the  evidence  of  the  underlying  cardiac  or  renal  disease. 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC,     323 

(d)  Acute  dyspnoea  in  young  infants  is  sometimes  due  to  en- 
larged thymus  (thymic  asthma).  The  diagnosis  rests  on  the  elimi- 
nation of  all  other  causes  for  sudden  dyspnoea  and  the  presence 
(sometimes)  of  increased  substernal  dulness. 

/^  SYPHILIS   OF   THE   LUNG. 

The  diagnosis  cannot  be  made  with  certainty  from  the  physical 
signs,  and  rests  entirely  (in  the  rare  cases  in  which  it  is  made  at  all) 
on  the  history,  the  evidence  of  syphilis  elsewhere  in  the  body,  and 
the  result  of  treatment.  Most  cases  are  mistaken  for  phtkisis. 

Any  case  supposed  to  be  phthisis,  but  in  which  the  examination 
of  the  sputa  for  tubercle  bacilli  is  repeatedly  negative,  should  be 
given  a  course  of  syphilitic  treatment. 

The  physical  signs,  as  in  phthisis,  are  those  of  localized  bron- 
chitis or  of  solidification,  but  the  lesions  are  not  at  the  apex  but 
usually  about  the  root  of  the  lung  or  lower  down.  Cavities  are  not 
formed.  Stenosis  of  a  bronchus  may  occur  with  resulting  atelecta- 
sis  of  the  corresponding  lobules. 

BRONCHIETASIS   (BRONCHIAL  DILATATION). 

(a)  The  commonest  type  is  that  associated  with  chronic  bron- 
chitis and  recurrent  attacks  of  winter  cough.  Innumerable  small 
bronchioles  become  dilated  and  the  resulting  cavity  infected — usu- 
ally— with  influenza  bacilli  (Win.  IT.  Smith).  The  signs  are  sim- 
ply those  of  a  chronic  bronchitis  with  or  without  emphysema  and 
asthmatic  seizures. 

(&)  When  the  disease  is  further  advanced  and  the  cavities  are 
larger,  a  sudden  change  in  the  patient's  position  (or  especially  hanging 
head  downward  over  the  side  of  the  bed)  may  cause  him  to  raise 
large  amounts  of  sputa  (half  a  pint  or  more)  within  a  few  minutes. 
This  sputum  is  not  usually  foul  and  rarely  contains  blood  or  elastic 
libres.  Even  at  this  stage  there  may  be  no  physical  signs  of  local- 
ized cavities — but  only  those  of  the  associated  bronchitis. 

(c)  In  a  small  number  of  cases  signs  of  cavity  (see  above,  p. 
313)  may  be  made  out. 


324  PHYSICAL  DIAGNOSIS. 

From  pulmonary  abscess  the  disease  may  usually  be  distinguished 
by  the  history,  the  sputa,  and  the  fact  that  local  signs  of  cavity 
surrounded  by  solidification  and  bronchitis  can  usually  be  demon- 
strated in  abscess. 

The  disease  may  cause  marked  retraction  of  the  chest  on  the 
affected  side,  and  neighboring  organs  may  be  drawn  out  of  place. 

CIRRHOSIS  OF  THE  LUNG. 
(Chronic  Interstitial   Pneumonia.) 

As  an  end  stage  of  unresolved  croupous  pneumonia,  or  as  a 
result  of  chronic  irritation  from  mineral  or  vegetable  dust,  a  shrink- 
age of  a  part  or  the  whole  of  the  lung  may  occur,  which  progresses 
until  the  pulmonary  tissue  is  transformed  into  a  fibrous  mass  en- 
closing bronchi. 

The  side  of  the  chest  corresponding  to  the  affected  lung  becomes 
shrunken  and  concave ;  fremitus  is  increased,  percussion  resonance 
diminished  or  lost,  respiration  tubular  with  coarse  rales. 

From  tuberculosis  the  condition  is  to  be  distinguished  solely  by 
the  histoiy,  the  absence  of  bacilli  in  the  sputa,  and  the  comparative 
mildness  of  the  constitutional  symptoms. 

The  right  ventricle  of  the  heart  may  become  hypertrophied  and 
later  dilated  with  resulting  tricuspid  insufficiency. 

EXAMINATION   OF   SPUTA. 

I.  Origin. — Probably  the  majority  of  all  sputa,  excepting  to- 
bacco juice,  come  from  the  nasopharynx,  and  are  hawked,  not 
coughed  up.  It  is  rarely  of  value  to  examine  such  sputa,  although 
influenza  bacilli,  diphtheria  bacilli,  pneumococci,  and  other  bacteria 
may  be  found. 

What  we  want  in  most  cases  is  sputa  coughed  up  from  the  pri- 
mary bronchi  or  lower  down,  and  the  patient  should  be  accordingly 
instructed.  Early  morning  cough  is  most  likely  to  bring  up  sputa 
from  the  bronchi. 

Young  children  do  not  raise  sputum,  but  when  it  is  important 
to  obtain  it  we  may  insert  the  forefinger  (covered  with  a  bit  of  cot- 
ton) into  the  pharynx,  so  as  to  excite  a  spasm  of  coughing.  The 


EMPHYSEMA,    ASTHMA,    PULMONARY  SYPHILIS,    ETC.    325 

sputum  is  deposited  on  the  cotton  before  the  child  has  time  to  swal- 
low it,  and  may  then  be  withdrawn  and  examined. 

II.  Quantity.  -If  the  amount  expectorated  is  large  (i.e.,  one- 
half  a  pint  or  more  in  twenty-four  hours),  we  may  be  dealing  with : 

1.  Pulmonary  oedema  (watery,  sometimes  pink  and  frothy). 

2.  Advanced  phthisis  (muco-purulent). 

3.  Ernpyema  ruptured  into  a  bronchus  (pure  pus). 

4.  Abscess  of  the  lung  (foul  smelling). 

5.  Bronchiectasis  (large  amount  within  a  few  minutes  on  change 
of  position). 

III.  Odor. — Unless  retained   in    a   lung  cavity   (abscess,  gan- 
grene) sputum  is  rarely  ill-smelling.     In  gangrene  of  the  lung  the 
breath  as  well  as  the  sputum  is  horribly  offensive,  and  the  odor  soon 
fills  the  room  and  the  house. 

IV.  Gross    Appearances. — (a)    Bloody    sputum    (haemoptysis) 
means  pure  or  nearly  pure  blood  in  considerable  quantity,   a  tea- 
spoonful  or  more,  not  mere  streaks  of  blood  in  muco-purulent  spu- 
tum, which  usually  comes  from  an  irritated  throat. 

Haemoptysis  thus  defined  is  seen  chiefly  in  the  following  condi- 
tions, arranged  in  the  order  of  frequency: 

1.  Phthisis.- 

2.  Pulmonary  congestion  with  infarction  (mitral  disease). 

3.  Pneumonia. 

4.  After  epistaxis. 

5.  Abscess  or  gangrene  of  the  lung. 

6.  Without  known  cause  ("vicarious  menstruation,"  etc.). 
Rare  causes  are  new  growths  of  the  lung,  parasites  (Distomum 

Westermanni),  aortic  aneurism  rupturing  into  an  air  tube,  ulcer  of 
the  trachea  or  bronchi. 

The  cause  of  haemoptysis  can  usually  be  made  out  by  a  thor- 
ough examination  of  the  chest  and  a  study  of  the  other  symptoms  in 
the  case.  In  phthisis  there  are  often  no  physical  signs  in  the  lungs 
at  the  period  when  the  bleeding  occurs  or  for  some  weeks  after  it. 
Blood  coughed  up  can  usually  be  distinguished  from  blood  vomited 
(hcematemesis~)  by  careful  questioning  and  by  examining  the  blood. 
Blood  coughed  up  often  contains  bubbles  of  air  and  is  alkaline  in 


326  PHYSICAL  DIAGNOSIS. 

reaction,  while  blood  from  the  stomach  is  usually  mixed  with  food, 
not  frothy,  and  perhaps  acid  in  reaction. 

(£)  Pneumonic  Sputum. — The  color  is  most  characteristic;  it  is 
either 

(1)  Tawny-yellow  or  fawn-colored  ("rusty"),  or 

(2)  Orange-juice  colored  (not  orange,  but  pale  straw  colored). 
These  colors,  associated  with  great  tenacity,  so  that  the  sputum 

clings  to  the  lips  and  does  not  fall  from  an  inverted  sputum-cup, 
are  almost  pathognomonic  of  pneumonia — though  pneumonia  often 
occurs  without  any  such  sputa. 

(c)  Serous  sputum,  profuse  and  watery,  is  characteristic  of  pul- 
monary osdema. 

(rf)  Black  or  gray  sputum  is  due  to  carbon,  dust,  or  tobacco  smoke 
inhaled. 

(e~)  Pure  pus — not  muco-purulent — is  oftenest  seen  in  influenza, 
occasionally  in  empyeuia  breaking  through  the  lung. 

(/)  Muco-purulent  sputum  occurs  in  many  diseases  and  is  char- 
acteristic of  none. 

IV.  Microscopic  Examination. — Ninety -nine-one-hundredths  of 
all  examinations  are  for  the  tubercle  bacillus.  Of  the  many  useful 
methods  of  staining  for  this  organism  the  following  seems  to  me 
the  best : 

1.  Pick   out   with  forceps  the   most  purulent  portion  of   the 
sputa  and  smear  it  thinly  over  a  cover  glass.      All  particles  thick 
enough  to  be  opaque  should  be  removed  from  the  cover  glass  be- 
fore staining. 

2.  Dry  the  preparation  held  in  the  fingers  over  a  Bunsen  or  al- 
cohol flame.     Then  fix  it  in  Cornet's  forceps  and  pass  it  three  times 
through  the  flame,  sputum  side  down. 

3.  Flood  it  with  carbolic  fuchsin,1  and  steam  it — do  not  boil  it 
— over  the  flame  for  about  thirty  seconds.     Be  sure  to  use  enough 
stain  so  that  it  does  not  dry  on  the  cover  glass. 

4.  Wash  in  water  and  decolorize  for  twenty  seconds  in  twenty - 
per-cent  HaS04. 

1  Carbolic -acid  crystals,  5  gm. ;  fuchsin  (saturated  alcoholic  solution),  10 
gm. ;  water,  100  gm. 


EMPHYSEMA,    ASTHMA,    PULMONARY  SYPHILIS,    ETC.    327 

5.  Wash  in  Avater  and  then  in  ninety-five-per-cent  alcohol  for 
thirty  seconds  or  until  the  color  ceases  to  come  out. 

6.  Wash  in  water  and  cover  with  Loftier' s  methylene  blue  l  for 
about  thirty  seconds. 

7.  Wash  in  water,  dry  on  blotting  paper,  and  mount  in  Canada 
balsam. 

The  whole  process  need  not  take  more  than  five  minutes,  and 
it  is  absolutely  essential  that  every  physician  should  be  familiar 
with  it. 

The  bacilli  are  stained  red,  everything  else  blue.  They  should 
be  looked  for  only  with  an  immersion  lens  (one-twelfth-inch),  a 
wide-open  diaphragm,  and  a  good  white  light.  In  the  vast  major- 
ity of  cases  the  bacilli  are  found,  if  at  all,  within  a  few  minutes 
and  in  almost  every  field.  Occasionally  one  has  to  search  longer, 
but  it  is  better  to  search  one  well-stained  preparation  thoroughly 
than  to  spend  the  time  in  preparing  and  examining  several. 

The  presence  of  red- stained  bacilli  in  specimens  of  sputa  so  pre- 
pared is  practically  pathognomonic  of  tuberculosis.  Other  acid- 
resisting  bacilli  occur  in  the  urine,  but  almost  never  in  the  lung. 

The  absence  of  tubercle  bacilli  after  at  least  six  examinations  of 
satisfactory  specimens 2  obtained  several  days  apart  makes  it  very 
unlikely  that  phthisis  is  present.  One  or  two  negative  examina- 
tions are  of  no  significance. 

Pheumoeocdo  and  Influenza  Bacilli. — For  both  these  organisms 
Gram's  stain  is  on  the  whole  the  best.  This  is  performed  as  fol- 
lows : 

1.  Prepare  a  smear  as  above  directed. 

2.  Cover  it  with    aniline-oil-gentian-violet    solution '  (freshly 
made  each  week)  and  heat  to  steaming  point. 

1  Saturated  alcoholic  solution  of  methylene  blue,  30  c.c. ;  aqueous  solution 
of  KOH  (1  in  10,000),  100  c.c. 

2  A  satisfactory  specimen  is  one  prepared  without  any  slips  in  technique 
from  purulent  sputa  obtained  by  coughing  and  not  by  hawking. 

3  Saturated  alcoholic  solution  of  gentian  violet,  13  c.c. ;  aniline  water,  84 
c.c. ;  aniline  water  is  the  clear  filtrate  from  the  mixture  of  aniline,  5  parts, 
with  water,  25  parts. 


328  PHYSICAL  DIAGNOSIS. 

3.  Wash  in  water  and  cover  with  IK  I  solution  1  for  thirty  sec- 
onds. 

4.  Wash   in  ninety-five-per-cent  alcohol  until  the   blue   color 
ceases  to  corne  out. 

5.  Counterstain  with  Bismarck  brown  for  thirty  seconds. 

6.  Wash  in  water  and  mount  in  Canada  balsam. 

The  pneumococcus  with  this  stain   comes   out  blue-black  and 
its  morphology  is  well  shown  (see  Fig.  166).     The  presence  of  a 


FIG.  166.— Pneumococci  in  Sputum.    (W.  H.  Smith.)     (Gram's  stain.) 

few  pneumococci  free  in  the  sputum  is  not  of  importance.  When 
the  organisms  are  very  abundant,  and  especially  when  many  of 
them  are  contained  within  leucocytes,  a  pneumococcus  infection  is 
strongly  suggested,  though  it  may  be  a  pneumococcus  bronchitis 
without  pneumonia.  In  the  earliest  stages  of  an  infection  fewer 

1  Iodine,  1  gin. ;  potassium  iodide,  2  gra. ;  water,  300  c.c. 


EMPHYSEMA,    ASTHMA,    PULMONARY  SYPHILIS,    ETC.     329 

organisms  are  found  within  leucocytes  than  is  the  case  later.  Ob- 
viously one  can  learn  only  by  practice  what  is  meant  by  "  few  "  or 
"  many  "  organisms. 

The  influenza  bacillus  is  the  smallest  organism  to  be  found  in 
the  sputum.  In  specimens  stained  by  Gram's  method  (as  above 
given)  the  influenza  bacilli  come  out  as  minute,  faintly  brown- stained 
points,  contrasting  with  the  intense  blue-black  of  pneumococci  and 
other  organisms.  Only  when  present  in  large  numbers  both  inside 
and  outside  the  leucocytes  of  the  sputa  are  they  diagnostic  of  active 
influenzal  infection,  since  the  organism  is  a  common  inhabitant  of 
the  upper  air  passages. 

Although  other  organisms — actinomyces,  micrococcus  catarrhalis, 
streptococcus,  bacillus  mucosus  capsulatus — are  sometimes  found  in 
sputa,  their  importance  does  not  justify  an  account  of  them  here. 

Indications  for  Sputum  Examination. — Any  cough  with  sputa 
lasting  more  than  a  week  calls  for  an  examination  of  sputa.  In 
doubtful  cases  of  influenza  or  pneumonia,  and  in  any  case  in  which 
tuberculosis  is  suspected,  an  examination  is  imperative. 

When  the  symptoms  or  physical  signs  suggest  tuberculosis  but 
no  sputa  can  be  obtained,  it  is  well  to  stimulate  the  bronchial  secre- 
tions with  10  gr.  of  potassium  iodide  after  meals  for  a  week.  A 
way  of  getting  sputa  from  young  children  has  already  been  de- 
scribed (page  324). 


CHAPTER   XVI. 

DISEASES   AFFECTING  THE  PLEURAL   CAVITY. 

I.  HTDKOTHORAX. 

/,  IN  cases  of  nephritis  or  of  cardiac  weakness  due  to  valvular 
heart  disease  a  considerable  accumulation  of  serum  may  take  place 
in  both  pleural  cavities.  The  physical  signs  are  identical  with 
those  of  pleuritic  effusion  (see  below,  page  336)  except  that  the 
latter  is  almost  always  unilateral,  while  hydrothorax  is  usually  bi- 
lateral. Exceptions  to  this  rule  occur,  however,  especially  on  the 
right  side  or  in  cases  in  which  one  pleural  cavity  has  been  obliter- 
ated by  fibrous  adhesions,  the  results  of  an  earlier  pleurisy.  The 
fluid  obtained  by  tapping  in  cases  of  hydrothorax  is  usually  con- 
siderably lower  in  specific  gravity  and  poorer  in  albumin  than  that 
exuded  in  pleuritic  inflammation. 

The  fluid  shifts  more  readily  with  change  of  position  than  is  the 
case  with  many  pleuritic  effusions,  owing  to  the  absence  of  adhe- 
sions in  hydrothorax. 

Friction  sounds,  of  course,  do  not  occur,  as  the  pleural  surfaces 
are  not  inflamed.  A  few  grains  of  potassium  iodide  by  mouth  soon 
produce  a  reaction  for  iodine  in  the  fluid  of  hydrothorax  and  not  in 
pleuritic  effusion. 

II   PNEUMOTHORAX. 

Pneumothorax,  or  the  presence  of  air  in  the  pleural  cavity,  may 
result  from  stabs  or  wounds  of  the  chest  wall,  but  is  usually  a  com- 
plication of  pulmonary  tuberculosis  which  weakens  the  lung  until 
by  a  slight  cough  or' even  by  the  movements  of  ordinary  respiration 
the  pulmonary  pleura  is  ruptured  and  air  from  within  the  lung  leaks 
into  the  pleural  cavity. 

If  the  opening  is  of  considerable  size,  and  the  air  is  not  hindered 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.         331 

\ 

or  encapsulated  by  adhesions,  great  and  sudden  dyspnoea  with  pain 
and  profound  "  shock  "  may  result.  More  commonly  the  air  enters 
the  pleural  cavity  gradually,  the  other  lung  has  time  to  hyper- 
trophy, and  the  heart  and  other  organs  become  gradually  accus- 
tomed to  their  new  situations. 

Physical  Signs. 

1.  Inspection. — The  affected  side  may  lag  behind  considerably  in 
the  movements  of  respiration.     In  very  marked  cases  it  is  almost 
motionless  and  the  interspaces  are  more  or  less  obliterated.     The 
diaphragm  is  much  depressed  and  Litten's  sign  absent.     In  right- 
sided  pneumothorax,  which  is  relatively  rare,  the  liver  is  depressed 
and  the  edge  can  be  felt  below  the  ribs. 

The  heart  is  displaced  as  by  pleuritic  effusion,  but  usually  to  a 
less  extent.  With  left-sided  pneumothorax  the  cardiac  impulse 
may  be  lowered  as  well  as  displaced,  owing  to  the  descent  of  the 
diaphragm. 

2.  Palpation.—  Frernitus  is  absent  over  the  lower  portions  of  the 
chest  corresponding  to  the  effused  air.     At  the  summit  of  the  chest 
over  the  retracted  lung,  fremitus  may  be  normal  or  increased.     In 
rare  cases  when  the  lung  is  adherent  to  the  chest  wall  and  cannot 
retract,  fremitus  is  preserved. 

The  positions  of  the  heart  and  liver  are  among  the  most  impor- 
tant points  determined  by  palpation.  Not  infrequently  no  cardiac 
impulse  is  to  be  obtained.  Sometimes  it  may  be  felt  to  the  right 
of  the  sternum  (see  Fig.  167)  or  in  the  left  axilla,  but  not  infre- 
quently it  is  so  fixed  by  pleuropericardial  adhesions  that  it  is  drawn 
upward  toward  the  retracted  lung  or  remains  near  its  normal  situa- 
tion. The  liver  is  greatly  depressed  in  cases  of  right-sided  pneumo- 
thorax, and  may  be  felt  as  low  as  the  navel. 

3.  Percussion. — Loud  tympanitic  resonance  is  the  rule  through- 
out the  affected  side.     Even  a  small  amount  of  air  is  sufficient  to  ren- 
der the  whole  side  tympanitic  and  often  to  obscure  the  dulness  which 
the  frequently  associated  pleural  effusion  would  naturally  produce. 
Indeed,  it  is  the  rule  that  small  effusions  are  wholly  masked  by  the 
adjacent  tympany. 


332  PHYSICAL  DIAGNOSIS. 

In  no  other  disease  do  we  get  such  clear,  intense  tympanitic 
resonance  over  the  chest. 

The  only  exception  to  this  rule  occurs  in  cases  in  which  the  air 
within  the  chest  is  under  great  tension,  making  the  chest  walls  so 
taut  that,  like  an  over-stretched  drum,  they  cannot  vibrate  properly. 
Under  these  conditions  the  percussion  note  becomes  muffled,  at 
times  almost  dull. 

Areas  of  dulness  corresponding  to  the  displaced  organs  (heart 
or  liver)  may  sometimes  be  percussed  out. 

4.  Auscultation. — Respiration  and  voice  sounds  are  usually  in- 
audible in  the  lower  portions  of  the  chest.  At  the  top  of  the  chest, 
and  rarely  in  the  lower  parts,  a  faint  amphoric  or  metallic  breathing 
may  be  heard,  but  as  a  rule  the  amphoric  quality  is  brought  out 
much  better  by  cough  which  is  followed  by  a  ringing  after-echo. 
Or  the  air  in  the  pleura  may  be  set  to  vibrating  and  made  to  give 
forth  its  characteristic,  hollow,  ringing  sound  if  a  piece  of  metal 
(e.g.,  a  coin)  be  placed  on  the  back  of  the  chest  and  struck  with 
another  coin,  while  we  listen  with  the  stethoscope  over  the  front  of 
the  chest  opposite  the  point  where  the  coin  is. 

The  clear  ringing  sound  heard  in  this  way  is  quite  different 
from  the  dull  chink  obtainable  over  sound  lung  tissue. 

The  "falling-drop  sound"  or  "metallic  tinkle,"  and  the  lung 
fistula  sound  are  occasionally  audible  (see  above,  p.  170). 

On  the  sound  side  the  breath  sounds  are  exaggerated.  At  the 
top  of  the  affected  side  over  the  collapsed  lung  the  breathing  is 
bronchial  and  rales  are  occasionally  heard. 

In  the  great  majority  of  cases  pneuuiothorax  is  complicated  by 
an  effusion  of  fluid  in  the  affected  pleural  cavity  and  we  have  then 
the  signs  of 

III.  PNEUMOSEROTHORAX  OK  PNEUMOPYOTHORAX. 

When  both  fluid  and  air  are  contained  in  the  pleural  cavity,  the 
patient  may  himself  be  able  to  hear  the  splashing  sounds  which 
the  movements  of  his  own  body  produce.  These  are  more  readily 
appreciated  if  the  observer  puts  his  ear  against  the  patient's  chest 
and  then  shakes  him  briskly.  Splashing  sounds  heard  within  the 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.        333 

chest  are  absolutely  pathognomonic  and  point  only  to  the  combina- 
tion of  fluid  and  air  within  the  pleural  cavity.  One  must  distin- 
guish them,  however,  from  similar  sounds  produced  in  the  stomach. 
By  observing  the  position  of  maximum  intensity  of  the  sounds,  this 
distinction  may  be  easily  made.  Unfortunately  the  critical  condi- 
tion of  the  patient  may  make  it  impossible  to  try  succussion,  as  in 
the  acute  cases  with  great  shock  it  is  dangerous  to  move  him  at  all. 


FIG.  167.— Pneumoserotnorax  Seen  from  Behind.  Note  the  horizontal  line  at  the  surface  of  the 
fluid  and  the  retracted  lung  just  above  the  inner  half  of  this  line.  Compare  Fig.  173. 
(From  v.  Ziemssen's  Atlas.) 

The  movements  of  breathing  or  coughing  may  bring  out  a  "  metal- 
lic tinkle  "  (see  above,  p.  332).  At  the  base  of  the  chest,  over  an 
area  corresponding  to  the  position  of  the  fluid,  an  area  of  dulness 
may  be  easily  marked  out  by  percussion,  and  this  area  shifts  very 
markedly  with  change  of  position.  The  shifting  dulness  of  pneu- 
moserothorax  is  strongly  in  contrast  with  the  difficulty  of  obtain- 
ing any  such  shift  in  ordinary  pleuritic  effusion  (see  Fig.  168). 


334 


PHYSICAL  DIAGNOSIS. 


(The  distinction  between  "open  pneumothorax,"  in  which  the 
rent  in  the  lung  through  which  the  air  escaped  in  the  pleura  re- 
mains open,  and  "closed  pneumothorax,"  in  which  the  rent  has 
become  obliterated — is  one  which  cannot  be  established  by  physi- 
cal signs  alone.  It  is  often  said  that  amphoric  breathing,  and  espe- 
cially an  amphoric  ring  to  the  voice  and  cough  sounds,  denote  an 

Contracted 
lung. 


Displaced 
heart. 


Air= 


**  Fluid- 


Liver.  «.——.— 


Tympany, 
breathing 
and  voice 
absent  or 

faint 
amphoric. 


Dulness, 
shifting 

with 

chanpe  ol 
position. 


FIG.  168.— Left  Pneumoserothorax  with  Displaced  Heart. 

open  pneumothorax,  but  post-mortem  evidence  does  not  bear  this 
out.  Practically  an  open  pneumothorax  is  one  in  which  the 
amount  of  effused  air  increases,  and  closed  pneumothorax  is  one  in 
which  the  physical  signs  remain  stationary  ) 

Differential  Diagnosis 

The  distinction  between  pneumothorax  and  emphysema  has  al- 
ready been  discussed. 

(«)  When  the  air  in  the  pleural  sac  is  under  such  tension  that 
the  percussion  note  is  dull,  the  physical  signs  may  simulate  pleu- 
ritic effusion,  but  real  flatness,  such  as  characterizes  effusion,  has 
not,  so  far  as  I  know,  been  recorded  in  pneumothorax,  and  the 
sense  of  resistance  on  percussing  is  much  greater  over  fluid  than 
over  air.  In  case  of  doubt  puncture  is  decisive. 


DISEASES  AFFECTING   THE  PLEURAL  CAVITY. 


335 


(&)  Acute  pneumothorax,  coming  on  as  it  does  with  symptoms 
of  collapse  and  great  shock,  may  be  mistaken  for  angina  pectoris, 
cardiac  failure,  embolism  of  the  pulmonary  artery,  or  acute  pulmo- 
nary tympanites  (see  above,  p.  315). 

From  all  these  it  can  be  distinguished  by  the  presence  of  am- 
phoric or  metallic  sounds,  which  are  never  to  be  obtained  in  the 
other  affections  named. 


Fio.  169.—  Diaphragmatic  Hernia.     The  outline  of  the  displaced  diaphragm  visible  below  the 
left  clavicle.    Heart  displaced  to  right  of  sternum.     (From  v.  Ziemssen's  Atlas.) 

(c)  Hernia  of  the  intestine  through  the  diaphragm  (see  Fig.  169) 
or  great  weakening  of  the  diaphragmatic  muscular  fibres,  may  allow 
the  intestines  to  encroach  upon  the  thoracic  cavity  and  simulate 
pneumothorax  very  closely.  The  history  and  course  of  the  case,  the 
abdominal  pain,  vomiting,  and  indicanuria,  generally  suffice  to  dis- 
tinguish the  condition.  The  peristalsis  of  the  intestine  may  go  on 
even  in  the  thorax,  and  gurgling  metallic  sounds  corresponding  to  it 
and  unlike  anything  produced  in  the  thorax  itself  may  be  audible. 


336  PHYSICAL  DIAGNOSIS. 

The  distinction  between  open  and  closed  pneumothorax,  to  which 
I  have  already  alluded,  is  far  less  important  than  the  presence  or 
absence  of 

(a)  Pulmonary  tuberculosis 

(5)  Encapsulating  adhesions  in  which  the  air  is  confined  to  a 
circumscribed  area- 

(a)  The  examination  of  the  sputa  and  of  the  compressed  lung 
may  yield  evidence  regarding  tuberculosis.     On  the  sound  side  the 
compensatory  hypertrophy  covers  up  foci  of  dulness  or  rales  so  that 
4t  is  difficult  to  make  out  much. 

(6)  Encapsulated  pneumothorax  gives  us  practically  all  the  signs 
of  a  phthisical  cavity,  from  which .  it  is  distinguished  by  the  fact 
that  with  a  cavity  the  nutrition  of  the  patient  is  almost  always 
much  worse. 

Encapsulated  pneumothorax  needs  no  treatment.  Hence  the 
importance  of  distinguishing  it  from  the  non-encapsulated  form  of 
the  disease,  in  which  treatment  is  essential. 

/  PLEURISY. 

Clinically,  we  deal  with  three  types : 

(a)  Dry  or  plastic  pleurisy. 

(b)  Pleuritic  effusion,  serous  or  purulent. 

(c)  Pleural  thickening. 

(a)  DRY  OR  PLASTIC  PLEURISY. 

Doubtless  many  cases  run  their  course  without  being  recognized. 
The  frequency  with  which  pleuritic  adhesions  are  found  post  mor- 
tem would  seem  to  indicate  this. 

It  is  usually  the  characteristic  stitch  in  the  side  which  suggests 
physical  examination.  The  pain  and  the  physical  signs  resulting 
from  the  fibrinous  exudation  are  usually  situated  at  the  bottom  of 
the  axilla  where  the  diaphragmatic  and  costal  layers  of  the  pleura 
are  in  close  apposition.  Doubtless  the  pleuritic  inflammation  is 
not  by  any  means  limited  to  this  spot,  but  it  is  here  that  the  two 
layers  of  the  pleura  make  the  largest  excursion  while  in  apposition 
with  each  other.  In  the  vast  majority  of  cases,  then,  the  physical 
signs  are  situated  at  the  spot  indicated  in  Fig.  170. 


DISEASES  AFFECTING   THE  PLEURAL  CAVITY. 


337 


Occasionally  pleuritic  friction  is  to  be  heard  in  the  precordial 
region,  and  after  the  absorption  of  a  pleuritic  effusion  evidences 
of  fibrinous  exudation  in  the  upper  parts  of  the  chest  are  sometimes 
demonstrable.  Most  rarely  of  all,  evidence  of  plastic  pleurisy  may 
be  found  at  the  apex  of  the  lung  in  connection  with  early  phthisis. 
In  diaphragmatic  pleurisy,  when  the  fibrinous  exudation  is  espe- 
cially marked  upon  the  diaphragmatic  pleura,  friction  sounds  may 
be  heard  over  the  region  of  the  attachment  of  the  diaphragm  in 
front  and  behind  as  well  as  in  the  axillae.  Hiccup  often  occurs  and 
gives  exquisite  pain. 

Our  diagnosis  is  based  upon  a  single  physical  sign,  pleuritic 
friction.  The  nature  of  this  sound  and  the 
manoeuvres  for  eliciting  it  have  already 
been  described  (see  above,  p.  166),  and  I 
will  here  only  recapitulate  what  was  there 
said.  During  the  first  few  deep  breaths 
one  hears,  while  listening  over  the  painful 
area,  a  grating  or  rubbing  sound  usually 
somewhat  jerky  and  interrupted,  most 
marked  at  the  latter  part  of  inspiration, 
but  often  audible  throughout  the  whole 
respiratory  act.  After  a  few  breaths  it 
often  disappears,  but  will  usually  reap- 
pear if  the  patient  lies  for  a  short  time 
upon  the  affected  side,  and  then  sits  up 
and  breathes  deeply.  In  marked  cases 
the  rubbing  of  the  inflamed  pleural  sur- 
faces may  be  felt  as  well  as  heard,  and  it 
is  not  very  rare  for  the  patient  to  be  able 
to  feel  and  hear  it  himself.  Pleuritic  fric- 
tion may  be  present  and  loud  without 
giving  rise  to  any  pain.  On  the  other 
hand,  the  pain  may  be  intense,  and  yet 
the  friction-rub  barely  audible.  When 
heard  at  the  summit  of  the  chest,  as  in 
cases  of  incipient  phthisis,  pleural  fric- 


FIG.  170.— Showing  the  Point  at 
which  Pleural  Friction  is  most 
Often  Heard. 


22 


338  PHYSICAL  DIAGNOSIS. 

tion  produces  only  a  faint  grazing  sound,  much  more  delicate  and 
elusive  tlian  the  sounds  produced  at  the  base  of  the  chest. 

Occasionally  the  distinctive  rubbing  or  grating  sounds  are  more 
or  less  commingled  with  or  replaced  by  crackling  sounds  indistin- 
guishable from,  the  drier  varieties  of  rales.  It  is  now,  I  think, 
generally  believed  that  such  sounds  may  originate  in  the  pleura  as 
well  as  within  the  lung.  The  greatest  care  should  be  taken  to 
prevent  any  shifting  or  slipping  of  the  stethoscope  upon  the  surface 
of  the  chest,  as  by  such  means  sounds  exactly  like  those  of  pleural 
friction  may  be  transmitted  to  the  ear.  In  case  of  doubt  one 
should  always  wet  or  grease  the  skin  so  that  the  stethoscope  can- 
not slip. 

Muscle  sounds  are  sometimes  taken  for  pleural  friction,  but  they 
are  bilateral,  usually  low-pitched,  sound  less  superficial  than  pleu- 
ral friction,  and  are  not  increased  by  pressure.  When  listening 
for  friction  at  the  base  of  the  left  axilla,  I  have  once  or  twice  been 
puzzled  by  some  low-pitched  rumbling  sounds  occurring  at  the  end 
of  inspiration,  and  due  (as  afterward  appeared)  to  gas  in  the  stom- 
ach which  shifted  its  position  with  each  descent  of  the  diaphragm. 

In  children  friction  sounds  and  pleuritic  pain  are  much  less 
common  than  in  adults,  and  the  signs  first  recognizable  are  those 
of  effusion.  In  adults  the  presence  of  a  very  thick  layer  of  fat 
may  make  it  difficult  or  impossible  to  feel  or  hear  pleural  friction. 

The  breath  sounds  over  the  affected  area  are  usually  absent  01 
greatly  diminished,  owing  to  the  restraint  in  the  respiratory  move- 
ments due  to  pain.  Not  infrequently  pleuritic  friction  may  be 
heard  altogether  below  the  level  of  the  lung. 

(£)  PLEURITIC  EFFUSION. 

Many  cases  are  latent,  and  the  patients  consult  the  physician  on 
account  of  slight  cough,  weakness,  or  gastric  trouble,  so  that  the 
effusion  is  first  discovered  in  the  course  of  routine  physical  ex- 
amination. Since  it  is  usually  the  results  of  percussion  which  first 
put  us  on  the  right  track,  I  shall  take  up  first 


DISEASES  AFFECTING   THE  PLEURAL   CAVITY. 


339 


Percussion. 

1.  A  small  effusion  first  shows  as  an  area  of  dulness 

(a)  Just  below  the  angle  of  the  scapula. 

(i)  In  the  left  axilla  between  the  fifth  and  the  eighth  rib. 

(c)  Obliterating  Traube's  semilunar  area  of  tympany;  or 

(d)  In  the  right  front  near  the  angle  made  by  the  cardiac  and 
hepatic  lines  of  dulness  (see  Fig.  171). 

In  the  routine  percussion  of  the  chest,  therefore,  one  should 
never  leave  out  these  areas.  A  small  effusion  is  most  easily  de- 
tected in  children  or  in  adults  with  thin  chest  walls,  provided  our 
percussion  is  not  too  heavy.  An  effusion  amounting  to  a  pint 
should  always  be  recognizable,  and  smaller  amounts  have  frequently 
been  diagnosed  and  proved  by  puncture. 

The  amount  of  a  pleuritic  effusion  is  roughly  proportional  to 
the  area  of  dulness  on  percussion,  but  not  accurately.  It  is  very 
common  to  find  on  puncture  an  amount  of  fluid  much  greater  than 


4.rea   of  dulness 
due    to    small  -c- 
pleural  effusion. 


--Area  of  cardiac 
dulness. 


FIG.  171.-Small  Pleural  Effusion  Accumulating  (in  part)  near  the  Right  Border  of  the  Heart. 

could  have  been  suspected  from  the  percussion  outlines ;  on  the  other 
hand,  the  dulness  may  be  extensive  and  intense  on  account  of  great 
inflammatory  thickening  of  the  costal  pleura,  by  the  accumulation 


340 


PHYSICAL  DIAGNOSIS. 


of  layer  after  layer  of  fibrinous  exudate  and  its  organization  into 
fibrous  plates,  while  very  little  fluid  remains  within. 

The  amount  of  dulness  depends  also  upon  the  thickness  and  elasti- 
city of  the  chest  wall  and  the  degree  of  collapse  of  the  lung  within. 

2.  Large  Effusions, — When  the  amount  of  fluid  is  large,  the  dul- 
ness may  extend  throughout  the  whole  of  one  side  of  the  chest  with 
the  exception  of  a  small  area  above  the  clavicle  or  over  the  primary 
bronchus  in  front.  This  area  gives  a  high-pitched  tympanitic  note, 


Normal  resonance 
and  vesicular 
breathing. 


Tympany,  voice  and 
fremitus  in- 
creased. 


Flatness,  no  breath- 
ing, voice  sounds, 
or  fremitus. 


Zone  of  condensed 
lung  above  the 
fluid. 


Exaggerated  (com- 
pensatory) breath- 
ing and  reso- 
nance. 


81».   173.-Diagram  to  Illustrate  Physical  Signs  in  Moderate-Sized  Effusion  in  the  Left  Pleura. 


provided  the  bronchi  remain  open,  as  they  almost  always  do.  This 
tympany  is  high-pitched  and  sometimes  astonishingly  clear.  I  re- 
cently saw  a  case  in  which  the  note  above  the  clavicle  was  almost 
indistinguishable  with  the  eyes  shut  from  that  obtained  in  the  epi- 
gastrium. Occasionally  "  cracked-pot "  resonance  may  be  obtained 
in  the  tyinpanitic  area. 

The  pitch  changes  if  the  patient  opens  and  closes  his  mouth 
while  we  percuss  ("Williams'  tracheal  tone  "). 

The  duluess  over  the  lower  portions  of  a  large  effusion  is  usual- 
ly very  marked,  and  the  percussing  finger  feels  a  greatly  increased 


DISEASES  AFFECTING   THE  PLEURAL   CAVITY. 


341 


resistance  to  its  blows  when  compared  with  the  elastic  rebound  of 
the  sound  side. 

3.  Moderate  Effusions. — Three  zones  of  resonance  can  often  be 
mapped  out  in  the  back:  at  the  base  dulness  or  flatness,  above 
that  a  zone  of  mingled  dulness  and  tympany,  and  at  the  top  normal 
resonance.  The  lowest  zone  corresponds  to  the  fluid,  the  middle 
zone  to  the  condensed  lung  immediately  above  it,  and  the  top  zone 
to  the  relatively  unaffected  part  of  the  lung  (see  Fig.  172).  Not 
infrequently  there  is  no  middle  zone  but  simply  dulness  below  and 
resonance  above,  as  is  usually  the  case  in  the  axilla  and  front 


FIG.  173.-  Left  Pleural  Effusion.     Note  that  the  surface  of  the  fluid  slopes  outward  and  up- 
ward from  the  median  line.    (From  v.  Ziemssen's  Atlas.) 

The  position  of  the  effusion  depends  only  in  part  upon  the  in- 
fluence of  gravity,  and  is  greatly  influenced  by  capillarity  and  the 
degree  of  retraction  of  the  lungs  Consequently  the  surface  of 
the  fluid  is  hardly  ever  horizontal  except  in  very  large  accurnula- 


342 


PHYSICAL  DIAGNOSIS. 


tions.  With  the  patient  in  an  upright  position  it  usually  reaches 
a  higher  level  in  the  axilla  than  in  the  back  (see  Fig.  173).  Near  the 
spine  and  near  the  sternum  (in  right-sided  effusions)  the  line  corre- 
sponding to  the  level  of  the  fluid  may  rise  sharply. 

The  S-curve  of  Ellis,  as  worked  out  so  elaborately  by  Garland, 
varies  still  further  the  uneven  line  which  corresponds  to  the  sur- 


Trlangular  space 
dull  until  patient 
has  coughed  and 
breathed  deeply. 


Area  of  dulness 
bounded  above  by 
the  8-curve  of 
Ellis. 


FIG.  174.-The  S-Curve  of  Ellis. 

face  of  the  fluid  (see  Fig.  174).  This  curve  can  be  obtained  only 
after  the  patient  has,  by  cough  and  forced  breathing,  expanded  the 
lung  as  fully  as  possible. 

All  these  curves  are  to  be  found  with  the  patient  in  the  upright 
position.  None  of  them  has  any  considerable  diagnostic  impor- 
tance, and  the  chief  point  to  be  remembered  is  that  the  upper  sur- 
face of  the  fluid,  not  being  settled  by  gravity  alone,  is  hardly  ever 
horizontal. 

With  change  in  the  position  of  the  patient  the  level  of  the  fluid 
sometimes  changes  very  slowly  and  irregularly,  and  sometimes  does 
not  change  at  all.  If,  for  purposes  of  thorough  examination,  we 
raise  to  a  sitting  posture  a  patient  who  has  been  for  some  days  or 
weeks  in  bed,  we  should  never  begin  the  examination  at  once,  since 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.         343 

it  may  take  some  minutes  for  the  lungs  and  the  fluid  to  accommo 
date  themselves  to  the  new  position.     It  is  well  also  to  get  the 
patient  to  cough  and  to  take  a  number  of  full  breaths  before  the 
examination  is  begun. 

To  test  the  mobility  of  the  fluid  with  change  of  the  patient's 
position,  mark  out  the  upper  limit  of  the  dulness  in  the  back  with 
the  patient  in  the  upright  position.  Then  let  the  patient  lie  face 
downward  upon  a  couch,  and,  after  waiting  a  few  minutes,  percuss 
the  previously  dull  area.  It  may  be  found  to  have  become  resonant. ! 

When  the  fluid  is  absorbed  or  removed  by  tapping,  one  would 
expect  an  immediate  return  of  the  percussion  resonance.  But  in 
fact  the  resonance  returns  very  slowly  and  is  wholly  unreliable  as 
a  test  of  the  amount  of  absorption  which  has  occurred.  Thickened 
pleura  and  atelectatic  lung  may  abolish  resonance  long  after  the 
fluid  is  all  gone.  We  depend  here  far  more  upon  the  evidence  ob- 
tained by  auscultation  and  palpation  and  on  the  general  condition 
of  the  patient. 

To  determine  the  returning  elasticity  of  the  lung  and  the  degree 
of  movability  of  its  lower  border,  percussion  is  very  useful  during 
the  stage  of  absorption.  After  percussing  out  the  lower  border  of 
pulmonary  resonance  in  the  back,  the  patient  is  directed  to  take  a 
long  breath  and  hold  it.  If  the  lung  expands,  the  area  of  percus- 
sion resonance  will  increase  downward. 

Percussion  aids  us  in  determining  whether  neighboring  organs 
are  displaced  by  the  pressure  of  the  accumulated  fluid.  The  liver 
is  often  pushed  down,  the  spleen  very  rarely.  Dislocation  of  the 
heart  is  one  of  the  most  important  of  all  the  signs  of  pleural  effu- 
sion, and  is  often  the  crucial  point  in  differential  diagnosis.  It  is 
a  very  striking  and  at  first  surprising  fact  that  a  left-sided  effusion 
displaces  the  heart  far  more  than  a  right-sided  effusion  of  the  same 

'This  test,  however,  is  somewhat  fallacious  and  of  very  little  diagnostic 
value,  since  the  lungs  tend  to  swing  up  toward  the  back  when  the  patient  lies 
prone,  even  when  no  fluid  is  present,  and  increase  of  resonance  in  the  back  with 
this  change  of  position  might,  therefore,  occur  when  the  dulness  was  due  to 
thickened  pleura  and  not  to  fluid. 


344  PHYSICAL  DIAGNOSIS, 

gize.  Small  or  moderate  right-sided  effusions  often  do  not  displace 
the  heart. at  all. 

With  left-sided  effusions,  unless  very  small,  we  find  the  area  of 
cardiac  dulness  shifted  toward  the  right  and  often  projecting  be- 
yond the  right  edge  of  the  sternum  (see  Fig.  173).  (Inspection  and 
palpation  often  give  us  even  more  valuable  Information  on  this 
point.  See  below,  p.  347.)  We  must  be  careful  to  distinguish  such 
an  area  of  dulness  at  the  right  sternal  margin  from  that  which  may 
be  produced  in  right-sided  effusions  by  the  fluid  itself  (see  above). 

As  mentioned  above,  a  right  pleural  effusion  may  very  early 
show  itself  as  an  area  of  dulness  along  the  right  sternal  margin. 
Light  percussion  will  usually  demonstrate  that  this  dulness  is  con- 
tinuous with  a  narrow  strip  of  flatness  at  the  base  of  the  axilla 
(ninth  and  tenth  ribs).  Such  an  effusion  is  late  in  creeping  up  the 
axilla.  It  appears  first  and  disappears  first  along  the  right  margin 
of  the  sternum. 

On  the  sound  side  the  percussion  resonance  is  often  increased, 
owing  to  compensatory  hypertrophy  of  the  sound  lung;  the  dia- 
phragm is  pushed  down  and  the  borders  of  the  heart  or  of  the  liver 
may  be  encroached  upon.  When  the  hyper-resonance  of  the  sound 
side  is  present,  it  should  warn  us  to  percuss  lightly  over  the  effu- 
sion, else  we  may  bring  out  the  resonance  of  the  distended  lung. 

Summary  of  Percussion  Signs. —  (1)  Flatness  corresponding 
roughly  to  the  position  of  the  fluid. 

(2)  Tympany  above  the  level  of  the  fluid  over  the  condensed 
lung. 

(3)  The  level  of  the  fluid  is  seldom  quite  horizontal. 

(4)  Shifting  of  the  fluid  with  change  of  position  is  rare,  slow, 
and  has  little  or  no  importance  in  diagnosis. 

Exceptions  and  Possible  Errors. — (a)  Great  muscular  pain  and 
spasm  may  produce  an  area  of  dulness  which  simulates  that  of 
pleural  effusions,  especially  as  the  auscultatory  signs  may  be  equally 
misleading.  A  hypodermic  of  morphine  will  dispel  the  dulness 
along  with  the  pain  if  it  is  due  to  muscular  cramp. 

(6)  If  the  lung  on  the  affected  side  fails  to  retract  (owing  to 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.        345 

emphysema  or  adhesions  to  the  chest  wall),  the  area  of  dulness  and 
its  intensity  will  be  much  diminished. 

(c)  It  must  be  remembered  that  dulness  in  Traube's  space  may 
be  due  to  solidification  of  the  lung,  to  situs  inversus,  to  tumors,  or  to 
overfilling  of  the  stomach  and  intestine  with  food,  as  well  as  to 
pleural  effusion;  also  that  the  size  of  the  tympanitic  space  varies 
greatly  in  health. 

(cT)  Earely  percussion  may  be  tympanitic  over  an  effusion  at 
the  left  base  owing  to  distention  of  the  stomach  or  colon. 

(e)  The  diagnosis  between  fluid  and  thickened  pleura  will  be 
considered  later. 

Auscultation. 

The  auscultatory  phenomena  vary  greatly  in  different  cases,  and 
in  the  same  case  at  different  times,  because  the  essential  condi- 
tions are  subject  to  similar  variations  Whatever  sounds  are  pro- 
duced in  the  lungs  or  in  the  bronchi  may  be  heard  over  the  fluid  un- 
less interfered  with  by  inflammatory  thickening  of  the  costal  pleura. 
Fluid  transmits  sounds  well,  but  there  may  be  no  breath  sounds  pro- 
duced and  hence  none  audible  over  the  fluid  Or  tubular  sounds 
only  may  be  produced  because  only  the  bronchi  remain  open,  the 
rest  of  the  lung  being  collapsed. 

Or  again,  if  rales  or  friction  sounds  are  produced  in  the  lung, 
they,  too,  may  be  transmitted  to  the  fluid  and  may  (alas !)  deter 
the  timid  "  observer  "  from,  tapping. 

In  about  two-thirds  of  all  large  effusions  no  breathing  at  all  is 
audible  over  the  area  of  flatness  on  percussion.  In  the  remaining 
third,  and  especially  in  children,  tubular  breathing,  sometimes 
feeble,  sometimes  very  intense,  is  to  be  heard. 

In  moderate  effusions  there  are  often  three  zones  in  the  back 
At  the  bottom  we  hear  nothing,  in  the  middle  zone  distant  bron- 
chial or  broncho-vesicular  breathing,  while  at  the  summit  of  the 
chest  the  breathing  is  normal. 

The  voice  sounds  correspond  When  breath  sounds  are  absent, 
the  voice  sounds  are  likewise  absent,  When  the  breathing  is  tubu- 


346  PHYSICAL  DIAGNOSIS. 

lar,  the  voice,  and  especially  the  whisper,  is  also  tubular  and  inten 
sified.  That  is,  whenever  the  bronchi  are  open,  the  lung  retracted, 
and  the  chest  walls  thin,  the  breathing,  voice,  and  whisper  will  corre- 
spond to  the  tracheal  and  bronchial  sounds.  Since  children  have  es- 
pecially thin  chest  walls,  these  bronchial  sounds  are  especially  fre- 
quent and  intense  in  children.1 

Near  the  angle  of  the  scapula  and  in  a  corresponding  position 
in  front,  the  sound  of  the  spoken  voice  may  have  a  peculiar  high- 
pitched,  nasal  twang,  to  which  the  term  egophony  is  applied. 
This  sign  has  no  importance  in  diagnosis,  since  it  is  not  constant, 
and  not  peculiar  to  fluid  accumulations. 

Kales  are  rarely  produced  in  the  retracted  lung,  and  so  are 
rarely  to  be  heard  over  the  fluid. 

All  these  sounds  may  be  diminished  or  abolished  if  the  costal 
pleura  is  greatly  thickened 

The  influence  of  cough  upon  the  lung,  and  so  upon  the  sounds 
produced  in  it  and  transmitted  through  the  fluid,  may  be  very  great 
and  very  puzzling  Rales  may  appear  or  disappear,  breathing 
change  in  quality  or  intensity,  and  in  the  differential  diagnosis  of 
difficult  cases  the  patient  should  always  be  made  to  cough  and  then 
breathe  deeply  before  the  examination  is  completed. 

In  very  large  effusions,  when  only  the  primary  bronchi  are 
open,  there  may  be  signs  like  those  of  pulmonary  cavity  at  the  site 
of  the  bronchi  in  front  or  behind  (amphoric  breathing,  large  metallic 
rales,  etc.).  Over  the  sound  lung  the  breathing  is  exaggerated  and 
extends  unusually  far  down  in  the  back  and  axilla,  owing  to  hyper- 
trophy of  the  lung. 

The  heart  sounds  may  be  absent  at  the  apex  owing  to  disloca- 
tion of  the  heart.  In  left-sided  effusions  the  apex  sounds  are  often 
loudest  near  the  ensifonn  cartilage  or  beyond  the  right  margin  of 
the  sternum  Right-sided  effusions  have  much  less  effect  upon  the 
heart,  but  occasionally  we  find  the  heart  sounds  loudest  at  the  left 
of  the  nipple  or  in  the  axilla. 

Since  many  cases  of  pleural  effusion  are  due  to  tuberculosis,  we 

•Bacelli's  theory  ^-that  the  whispered  voice  is  conducted  through  serum 
but  not  through  pus — is  not  borne  out  by  facts. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.          347 

should  never  omit  to  search  for  evidences  of  this  disease  at  the 
apex  of  the  lung  on  the  sound  side,  since  experience  has  shown  that 
phthisis  is  more  apt  to  begin  here  than  on  the  side  of  the  effusion. 

Summary  of  Auscultatory  Signs. 

(1)  In  most  cases  voice  and  breath  sounds  are  absent  or  very 
feeble  over  the  area  occupied  by  the  fluid. 

(2)  In  a  minority  of  the  cases  the  breathing  and  voice  sounds 
may  be  tubular  and  intensified,  especially  in  children. 

(3)  Over  the  condensed  lung  at  the  summit  of  the  chest  the 
breathing  is  bronchial  or  broncho-vesicular,  according  to  the  degree 
of  condensation.     If  the  amount  of  fluid  is  small,  the  layer  of  con- 
densed lung  occupies  the  middle  zone  of  the  chest  and  the  breath- 
ing is  normal  at  the  top  of  the  chest. 

(4)  Rales  and  friction  sounds  are  rarely  heard  over  fluid. 

(5)  On  the  sound  side  the  breathing  is  exaggerated. 

(6)  The  heart  sounds  may  be  absent  at  the  apex  and  present  in 
the  left  axilla  or  to  the  right  of  the  sternum  owing  to  dislocation 
of  the  heart. 

Inspection  and  Palpation. 

The  most  important  information  given  us  by  inspection  and 
palpation  relates  to  the  displacement  of  various  organs  by  the  pres- 
sure of  the  accumulated  fluid.  In  left-sided  pleuritic  effusions  the 
heart  is  usually  displaced  considerably  toward  the  right,  even  when 
the  level  of  the  fluid  reaches  no  higher  than  the  sixth  rib  in  the 
nipple  line.  The  impulse  is  then  to  be  seen  and  felt  to  the  right 
of  the  sternum,  somewhere  between  the  third  and  the  seventh  rib, 
when  a  large  amount  of  fluid  is  present.  With  smaller  effusions 
one  may  find  the  apex  beat  lifting  the  sternum  or  close  to  its  left 
border.  The  position  of  the  heart  may  be  confirmed  by  percussion. 

The  spleen  is  scarcely  ever  displaced. 

Eight-sided  effusions  are  far  less  likely  to  displace  the  heart,  and 
it  is  only  when  a  large  amount  of  fluid  is  present  that  the  apex  of 
the  heart  is  pushed  outward  beyond  the  nipple.  Moderate  right- 
sided  effusions  often  produce  no  dislocation  of  the  heart  whatever. 
The  liver  is  often  considerably  pushed  down  by  a  right-sided  pleu- 


348  PHYSICAL  DIAGNOSIS. 

ritic  effusion,  and  its  edge  may  be  palpable  several  inches  below  the 
costal  margin.  Its  upper  margin  cannot  be  determined  by  percus- 
sion, as  it  merges  into  the  flatness  produced  by  the  fluid  accumula- 
tion above  it. 

Tactile  fremitus  is  almost  invariably  absent  or  greatly  dimin- 
ished over  the  areas  corresponding  to  the  fluid ;  just  above  the  level 
of  the  fluid  it  is  often  increased. 

Occasionally  a  slight  fulness  of  the  affected  side  may  be  recog- 
nized by  inspection,  and  the  interspaces  may  be  less  readily  visible 
than  upon  the  sound  side.  Bulging  of  the  interspaces  I  have  never 
observed.  When  the  accumulation  of  fluid  is  large  the  respiratory 
movements  upon  the  affected  side  are  somewhat  diminished,1  the 
shoulder  is  raised,  and  the  spine  curved  toward  the  affected  side. 
The  diaphragm  is  depressed,  and  Litten's  sign  therefore  absent. 

There  are  no  reliable  means  for  distinguishing  purulent  from 
serous  effusions.  The  whispered  voice  may  be  transmitted  through 
either  pus  or  serum.  But  we  know  that  in  children  two-thirds  of 
all  effusions  are  purulent,  while  in  adults  three-fourths  of  them  are 
serous. 

Physical  Signs  During  Absorption  of  Pleural  Effusions. 

When  the  fluid  begins  to  disappear,  either  spontaneously  or  as 
a  result  of  treatment,  the  dulness  very  gradually  disappears  and 
the  breath  sounds,  voice  sounds,  and  fremitus  reappear.  In  case 
the  heart  has  been  dislocated,  its  return  to  its  normal  position  is 
often  much  slower  than  one  would  anticipate,  and  indeed  all  the 
physical  signs  are  disappointingly  slow  to  clear  up  even  after  tap- 
ping. Pleural  friction  appears  when  the  roughened  pleural  surfaces, 
which  have  been  held  apart  by  the  fluid,  are  allowed  by  the  disap- 
pearance of  the  latter  to  come  into  apposition  again.  Owing  to  pul- 
monary atelectasis  and  permanent  thickening  of  the  pleura,  con- 
siderable dulness  often  remains  for  weeks  after  the  fluid  has  been 
absorbed. 

1 1  have  purposely  made  but  little  of  the  changes  in  the  shape  of  the  chest 
produced  by  pleuritic,  effusions,  as  it  has  seemed  to  me  that  by  far  too  much 
stress  has  usually  been  laid  upon  such  signs. 


DISEASES  AFFECTING   THE  PLEURAL   CAVITY. 


349 


Interlobar  Empyema. 

In  recent  years  the  frequency  and  importance  of  empyema  lim- 
ited to  an  interlobar  fissure  has  become  impressed  upon  many  clin- 
icians. I  have  seen  both  the  post-pneumonic  and  the  tuberculous 
types.  In  most  of  the  cases  so  far  reported  the  pus  has  been  de- 
monstrated in  the  fissure  which  runs  along  the  vertebral  border  of 


Compressed  areas  of 
lung,  showing  in- 
tense tubular 
breathing  and 
whisper  with  dul- 
ii  ess. 


Flatness. 
Diminished  or  absent 

breathing. 
Diminished  or  absent 

voice. 


FIG.  174A.— Signs  In  Interlobar  Empyema. 

the  scapula  when  that  bone  is  pulled  as  far  forward  as  possible  by 
crossing  the  arms  in  front  (see  Fig.  174A). 

This  is  a  region  seldom  carefully  examined. 

In  the  strip  here  indicated  one  finds  flatness  on  percussion  with 
(usually)  diminished  fremitus,  and  feeble  or  absent  breath-sounds. 
Jt'-ray  examination  may  bring  out  in  sharp  relief  a  shadow  corre- 
sponding to  this  area  and  sharply  contrasted  with  the  relatively 
normal  lung  above  and  below  it. 

The  exploring  needle  often  fails  to  find  the  pus,  but  the  search 
should  not  be  given  up  (if  the  physical  signs  are  clear)  until  a  rib 
has  been  excised  and  the  region  thoroughly  explored  under  complete 
anaesthesia. 


350  PHYSICAL  DIAGNOSIS. 

(c)  PLEURAL  THICKENING. 

In  persons  who  have  previously  suffered  from  pleurisy  with 
effusion,  and  in  many  who  have  never  to  their  knowledge  had  any 
such  trouble,  a  considerable  thickening  of  the  pleural  membrane 
with  adhesion  of  the  costal  and  visceral  layers  may  be  manifested 
by  the  following  signs : 

(1)  Dulness  on  percussion,  sometimes  slight,  sometimes  marked. 

(2)  Diminished  vesicular  respiration. 

(3)  Voice  sounds  and  tactile  fremitus  diminished  or  increased. 

(4)  Absence  of   Litten's  phenomenon  and   diminution  in  the 
normal  respiratory  excursion  of  the  chest. 

These  signs  are  most  apt  to  be  found  at  the  base  of  the  lung 
behind  and  in  the  axilla.  Occasionally  a  similar  thickening  may 
be  demonstrated  throughout  the  whole  extent  of  the  pleura,  and  the 
lung  failing  to  expand,  the'  chest  may  fall  in  as  a  result  of  atmos- 
pheric pressure  (see  Fig.  51). 

The  ribs  approximate  and  may  overlap,  the  spine  becomes 
curved,  the  shoulder  lowered,  the  scapula  prominent,  and  the  whole 
side  shrunken.  The  heart  may  be  drawn  over  toward  the  affected 
side. 

In  the  diagnosis  of  pleural  thickening  Rosenbach's  "palpatory 
puncture  "  is  sometimes  our  only  resource.  Under  antiseptic  pre- 
cautions a  hollow  needle  is  pushed  between  the  ribs  and  into  the 
pleural  cavity.  As  the  needle  forces  its  way  through  the  tough 
fibrous,  or  perhaps  calcified,  pleura,  the  degree  and  kind  of  resist- 
ance are  very  enlightening.  Again,  the  amount  of  mobility  of  the 
point  after  the  chest  wall  has  been  pierced  tells  us  whether  the 
needle  is  free  in  a  cavity,  entangled  in  a  nest  of  adhesions,  or  fixed 
in  a  solid  "  carnified  "  lung.  There  is  no  danger  if  the  needle  is 
sterile. 

ENCAPSULATED  PLEURAL  EFFUSION. 

Small  accumulations  of  serum  or  pus  may  be  walled  off  by  ad- 
hesions so  that  the  fluid  does  not  gravitate  to  the  lowest  part  of 
the  pleural  cavity  or  spread  itself  laterally  as  it  would  if  free 


DISEASES  AFFECTING   THE  PLEURAL  CAVITY.        351 

Such  localized  effusions  are  most  apt  to  be  found  in  the  lower  axil- 
lary regions  or  behind — sometimes  between  the  base  of  the  lung  and 
the  diaphragm,  and  more  often  between  the  lobes  of  one  of  the 
lungs  or  higher  up.  I  have  twice  seen  an  encapsulated  purulent 
effusion  so  close  to  the  left  margin  of  the  heart  that  the  diagnosis 
of  pericardial  effusion  was  made. 

The  diagnosis  of  encapsulated  pleural  effusion  is  a  difficult  one 
and  oftentimes  cannot  be  made  except  by  puncture.  The  signs  are 
those  of  fluid  in  the  pleura,  but  anomalously  placed.  Even  punc- 
ture may  fail  to  clear  up  the  difficulty,  since  the  needle  may  pass 
entirely  through  the  pouch  of  fluid  and  into  some  structure  behind 
so  that  no  fluid  is  obtained. 

PULSATING  PLEURISY. 

Under  conditions  not  altogether  understood  the  movements 
transmitted  by  the  heart  to  a  pleural  effusion  (usually  purulent) 
may  be  visible  externally  as  a  circumscribed  pulsating  swelling  near 
the  precordial  region,  or  as  a  diffuse  undulation  of  a  considerable 
portion  of  the  chest  wall.  Sometimes  this  pulsation  is  visible  be- 
cause the  fluid  has  worked  its  way  out  through  the  thoracic  wall 
and  is  covered  only  by  the  skin  and  subcutaneous  tissues,  but  occa- 
sionally pulsation  in  a  pleural  effusion  becomes  visible,  although  no 
such  perforation  of  the  chest  wall  has  occurred. 

The  condition  is  a  rare  one,  and  is  of  importance  only  because  it 
may  be  mistaken  for  an  aneurism,  from  which,  however,  it  should 
be  readily  distinguished  by  the  absence  of  a  palpable  thrill  or  dias- 
tolic  shock  and  by  the  evidence  of  fluid  in  the  pleura. 

DIFFERENTIAL  DIAGNOSIS  OF  PLEURITIC  EFFUSION. 

The  following  conditions  are  not  infrequently  mistaken  for 
pleuritic  effusion : 

(1)  Croupous  pneumonia  with  occlusion  of  the  bronchi. 

(2)  Pleural  thickening,  with  pulmonary  atelectasis. 

(3)  Subdiaphragmatic  abscess  or  abscess  of  the  liver. 

In  croupous  pneumonia  with  plugging  of  the  bronchi  one  may 


352  PHYSICAL  DIAGNOSIS. 

have  present  all  the  physical  signs  of  pleuritic  effusion  except  dis- 
placement of  the  neighboring  organs.  The  presence  or  absence  of 
such  displacement,  together  with  the  history,  symptoms,  and  course 
of  the  case,  is  therefore  our  mainstay  in  distinguishing  the  two 
diseases. 

From  ordinary  croupous  pneumonia  (without  occlusion  of  the 
bronchi)  pleuritic  effusion  differs  in  that  it  produces  a  greater  de- 
gree of  dulness  and  a  diminution  of  the  spoken  voice  sounds  and 
tactile  frernitus.  Bronchial  breathing  and  bronchial  whisper  may 
be  heard  either  over  solid  lung  or  over  fluid  accumulation,  although 
the  bronchial  sounds  are  usually  feeble  and  distant  in  the  latter 
condition.  The  displacement  of  the  neighboring  organs  is  of  im- 
portance here  as  in  all  diagnoses  in  which  pleuritic  effusion  is  a 
possibility.  In  pleuritic  effusion  we  can  sometimes  determine  that 
the  line  marking  the  upper  limit  of  dulness  shifts  with  change  of 
the  patient's  position.  This  is,  of  course,  impossible  in  pneumo- 
nia. A  few  hard  coughs  may  open  up  an  occluded  bronchus  and 
so  clear  up  the  diagnosis  at  once.  In  doubtful  cases  the  patient 
should  always  be  made  to  cough  and  breathe  deeply  before  the 
examination  is  finished. 

It  should  always  be  remembered  that  one  may  have  both  pneu- 
monia and  pleuritic  effusion  at  the  same  time,  and  that  pneumonia 
is  often  followed  by  a  purulent  effusion.  In  children  the  bronchi 
are  especially  prone  to  become  occluded  even  as  a  result  of  a  simple 
bronchitis,  and  we  must  then  differentiate  between  atelectasis  and 
effusion — in  the  main  by  the  use  of  the  criteria  just  described. 

(2)  It  is  sometimes  almost  impossible  to  distinguish  small  fluid 
accumulations  in  the  pleural  cavity  from  pleural  thickening  with 
pulmonary  atelectasis.  In  both  conditions  one  finds  dulness,  dimi- 
nution of  the  voice  sounds,  respiration,  and  tactile  fremitus,  and 
absence  of  Litten's  phenomenon,  but  the  tactile  fremitus  is  usually 
more  diminished  when  fluid  is  present  than  in  simple  pleural  thick- 
ening and  atelectasis.  An  area  of  dulness  which  shifts  with  change 
of  position  points  to  pleuritic  effusion.  The  presence  of  friction 
sounds  oVer  the  suspected  area  speaks  strongly  in  favor  of  pleural 
thickening,  but  it  is  possible  to  hear  friction  sounds  over  fluid, 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.        353 

probably  because  they  are  conducted  from  a  point  higher  up  in  the 
chest  at  which  no  fluid  is  present.  In  doubtful  cases  the  diagnosis 
can  and  should  be  cleared  up  by  puncture. 

(3)  In  two  cases  I  have  known  enlargement  of  the  liver  due  to 
multiple  abscesses  to  be  mistaken  for  empyema.  In  both  condi- 
tions, one  finds  in  the  right  back  dulness  on  percussion  as  high  as 
mid-scapula,  with  absence  of  voice  sounds,  breath  sounds,  and 
fremitus.  These  conditions  are  due  in  one  case  to  the  presence  of 
fluid  between  the  lung  and  the  chest  wall,  and  in  the  other  case  to 


PIG.  175,-Area  of  Dulness  in  Solitary  (tropical)  Abecess  of  the  Liver. 

the  liver  which  pushes  up  the  lung  together  with  the  diaphragm. 
Without  the  fluoroscope  or  a  good  radiograph  this  diagnosis  may  be 
impossible.  With  the  fluoroscope  it  should  be  possible  to  see  that 
the  dome  of  the  diaphragm  caps  the  shadow  and  moves  down  with 
it  during  inspiration.  Some  of  the  symptoms,  such  as  chills,  sweat- 
ing, and  irregular  fever,  are  common  to  both  conditions.  A  careful 
consideration  of  the  history  and  the  associated  signs  and  symptoms 
may  help  us  to  decide. 

Large  solitary  abscess  of  the  liver,  occurring  as  it  almost  in- 
variably does  in  the  posterior  portions  of  the  right  lobe,  produces  an 
area  of  flatness  on  percussion,  which  rises  to  a  much  higher  level  in 
23 


354 


PHYSICAL  DIAGNOSIS. 


the  axilla  and  back  than  in  front  or  near  the  sternum  (see  Fig.  175), 
and  may  be  in  this  way  distinguished  from  empyema;  but  when  the 
liver  contains  many  small  abscesses,  as  in  suppurative  cholangitis, 
this  peculiar  line  of  dulness  is  not  present. 

(d)  Rare  diseases,  such  as  cancer  or  hydatid  of  the  lung,  may 
be  mistaken  for  pleuritic  effusion.  The  history  of  the  case  and  the 
results  of  exploratory  puncture  usually  clear  up  the  difficulty. 

Examination  of  Exudates  and  Transudates. 

Only  such  methods  as  can  be  carried  out  without  a  thermostat 
will  be  here  described.  Hence  the  examination  of  diphtheria 
swabs,  blood  cultures,  and  pus  are  excluded.  We  have  left  the 


FIG.  176.— Lymphocytosis  in  Pleural  Fluid.    Primary  tuberculous  pleurisy.    (X  750  diameters.) 

(Musgrave.) 

fluids  obtained  by  tapping  the  pleura,  the  peritoneum,  and  the  spinal 
cord.     The  first  is  the  most  important. 


DISEASES  AFFECTING   THE  PLEURAL  CAVITY.        355 

Pleural  Fluids. — A  fluid  withdrawn  from  the  pleura  by  punct- 
ure may  be  a  mechanical  transudate  (hydrothorax),  may  be  evi- 
dence of  tuberculous  pleurisy  (primary  or  associated  with  phthisis), 
or,  rarely,  an  exudate  of  septic  or  cancerous  origin. 

To  investigate  these  fluids  we  note : 

1.  Color.     Bloody  fluids  suggest  cancer,  but  occasionally  occur 
in  pneumonia  and  tuberculosis. 

2.  Weight.1     Dropsical  fluid  is  generally  below  1.015  in  specific 


FIG.  177.— Polynuclears  and  Large  Lymphocytes  in  Pleural  Fluid  from  a  Case  of  Traumatic 
Acute  Infectious  Pleurisy.    (X  750  diameters.)     (Musgrave.) 

gravity.  Exudates  are  usually  in  the  vicinity  of  1.020.  An  ordi- 
nary specific-gravity  bulb  is  used. 

3.   The  cells  of  the  sediment  (cytodiagnosis). 

Technique  of  Cytodiagnosis. — 1.  Pour  fluid  into  tubes  of  a  cen- 
trifuge and  centrifugalize  five  minutes. 

2.   Pour  off  the  supernatant  fluid  and  stir  up  the  sediment  with 

1  The  amount  of  albumin  usually  runs  parallel  with  the  weight  of  the  fluid. 


356 


PHYSICAL  DIAGNOSIS. 


a  platinum  loop,  so  as  to  suspend  the  sediment  in  the  few  remain- 
ing drops. 

3.  Spread  a  drop  of  the  mixture  on  a  clean  cover  glass  with  the 
platinum  loop  and  let  the  smear  dry  without  heating  it. 

4.  Stain  like  a  blood  film  (see  below,  page  471)  with  the  follow- 


FIG.  178.— Pleural  Fluid  in  Hydrothorax  Due  to  Cardiac  Disease.    Endothelial  plaques  and  cells. 
(X  750  diameters.)    (Musgrave.) 


ing  mixture: '  Wright's  modification  of  Irishman's  stain,  3  parts; 
pure  methyl  alcohol,  1  part. 

5.  After  staining,  wash  very  gently,  using  a  dropper  (else  the 
whole  film  may  be  pushed  off),  and  dry  in  the  fingers  over  a  Hun- 
sen  or  alcoholic  flame.     Do  not  blot  the  preparation. 

6.  Mount  in  Canada  balsam  and  examine  with  an  oil-immersion 
lens. 

Interpretation  of  Results. — (a)  In  tuberculous  pleurisy,  lympho- 

1  Suggested  by  Musgrave:  Boston  Med.  and  Surg.  Jouru.,vol.  cli.,  p.  319,  1904. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.        357 

cytes  make  up  from  seventy  to  ninety-nine  per  cent — usually  over 
ninety  per  cent — of  all  the  cells  found  in  the  smeari(see  Fig.  176). 

(I)  In  septic,  cases  due  to  the  streptococcus,  staphylococcus,  or 
pneumococcus  the  majority  of  the  cells  are  polynuclear  leucocytes 
(see  Fig.  177). 

(c)  In  transudations  (dropsical)  the  predominating  cell  is  a  large 
mononuclear  type,  apparently  endothelial  in  origin  and  often  occur- 
ring in  sheets  or  "plaques"  (see  Fig.  178). 

Exceptions  occasionally  occur,  but  in  the  main  these  rules  are 
sufficiently  exact  to  be  of  value  in  diagnosis  when  taken  in  connec- 
tion with  all  the  facts  in  the  case. 

In  peritoneal  fluid  the  use  of  cytodiagnosis  has  not  as  yet  fur- 
nished information  of  any  considerable  diagnostic  value. 

In  cerebiospinal  fluid  obtained  by  lumbar  puncture  the  predom- 
inance of  lymphocytes  is  not  so  often  associated  with  tuberculosis  as 
it  is  in  the  pleura,  but  usually  means  chronic  cerebrospinal  irrita- 
tion such  as  is  produced  by  dementia  paralytica  and  tabes.  An 
excess  of  polynuclear  cells  is  usually  due  to  acute  meningitis, — 
epidemic  or  sporadic. 

'This  rule,  however,  does  not  work  both  ways.  Tuberculosis  produces 
lymphocytosis,  but  so  do  other  chronic  irritations.  The  lymphocytosis  is  a 
mark  of  chronicity  and  only  suggests  tuberculosis,  but  there  are  no  other  com- 
mon causes  for  chronic  pleural  irritation. 


CHAPTER   XVII. 

ABSCESS,   GANGRENE,  AND    CANCER   OF    THE    LUNG, 
PULMONARY  ATELECTASIS,  (EDEMA,  AND   HYPO- 
STATIC   CONGESTION. 

ABSCESS  AND  GANGRENE  OF  THE  LUNG. 

I  CONSIDER  these  two  affections  together  because  the  physical 
signs,  exclusive  of  the  sputa,  do  not  differ  materially  in  the  two 
affections.  In  some  cases  there  may  be  no  physical  signs  at  all, 
and  the  diagnosis  is  made  from  the  character  of  sputa  and  from  a 
knowledge  of  the  etiology  and  symptomatology  of  the  case.  In 
other  cases  we  find  nothing  more  than  a  patch  of  coarse  rales  or  a 
small  area  of  solidification,  over  which  distant  bronchial  breathing, 
with  increased  voice  sound  and  freniitus,  may  be  appreciated. 
Rarely  there  may  be  slight  dulness  on  percussion,  but  as  a  rule  the 
area  is  not  sufficiently  large  or  sufficiently  superficial  to  produce 
this.  One  may  find  the  signs  of  cavity  (amphoric  breathing, 
cracked-pot  resonance,  and  gurgling  rales),  but  this  is  unusual. 

Gangrene  of  the  lung  is  not  a  common  disease.  The  diagnosis 
usually  rests  altogether  upon  the  smell  and  appearance  of  the  sputa. 
In  fetid  bronchitis  one  may  have  sputa  of  equal  foulness,  but  the 
odor  is  different.  The  finding  of  elastic  tissue  in  the  sputa  proves 
the  existence  of  something  more  than  bronchitis. 

Pulmonary  abscess,  which,  like  gangrene,  is  a  rare  affection,  is 
often  simulated  by  the  breaking  of  an  empyema  into  the  lung  and 
the  emptying  of  the  pus  through  a  bronchus.  Large  quantities  of 
pus  are  expectorated  in  such  a  condition,  and  abscess  of  the  lung  is 
suggested,  but  the  other  physical  signs  are  those  of  empyema  and 
should  be  easily  recognized  as  such.  The  finding  of  elastic  fibres 
is  the  crucial  point  in  the  diagnosis  of  intrapulmonary  abscess, 


360  PHYSICAL   DIAGNOSIS. 

whether  due  to  the  tubercle  bacillus  or  to  other  organisms.  Tuber- 
culous abscess  (cavity)  is  usually  near  the  summit  of  the  lung,  and 
other  varieties  of  abscess  are  near  the  base,  but  often  there  are 
no  physical  signs  by  which  we  can  distinctly  localize  the  process. 

MALIGNANT  DISEASE  or  THE  LUNG,  PLEURA,  OR  CHEST  WALL. 

In  its  earlier  stages  this  affection  is  often  mistaken  for  empy- 
ema  or  serous  effusion  in  the  pleural  cavity,  and  indeed  the  physi- 
cal signs  may  be  due  wholly  to  an  accumulation  of  fluid  secondary 
to  the  malignant  growth  within  the  lung.  The  rapid  emaciation 
of  the  patient  and  the  rapid  reaccumulation  of  a  dark-brown  bloody 
fluid  in  the  pleural  cavity,  after  puncture,  make  us  suspect  malig- 
nant disease,  but  in  sarcoma  there  is  usually  no  emaciation  until 
late  in  the  course  of  the  disease.  The  sputa  rarely  contain  frag- 
ments of  tissue  whose  structure  can  be  recognized  as  characteristic  of 
malignant  disease.  Secondary  deposits  in  the  supraclavicular  glands 
may  suggest  the  diagnosis. 

The  thorax  is  usually  somewhat  asymmetrical.  The  affected 
side  may  be  either  contracted  or  distended  according  to  the  nature 
of  the  malignant  growth  within;  occasionally  it  is  not  deformed 
at  all.  When  the  growth  attacks  only  the  lung  tissue  itself,  leaving 
the  bronchi  and  mediastinum  free,  we  get  signs  like  those  of  pleu- 
ral effusion  (flatness,  absent  breathing,  voice  sounds,  and  tactile 
fremitus). 

If  the  disease  begins  in  the  bronchi,  we  may  have  a  noisy  dysp- 
noea from  stenosis  of  a  bronchus,  and  a  weakening  of  the  respiratory 
sounds  normally  to  be  heard  over  the  trachea  in  front  has  several 
times  been  noted.  Percussion  dulness,  if  present,  is  usually  over 
the  upper  portions  of  the  chest,  and  may  disappear  and  reappear 
or  skip  from  place  to  place  in  a  very  irregular  and  confusing  way. 

Signs  and  symptoms  of  pressure  in  the  mediastinum  due  to  sec- 
ondary involvement  of  the  peribronchial  glands  may  be  present  and 
may  simulate  aneurism,  or  the  growth  may  press  directly  upon  the 
brachial  plexus,  producing  pain  in  the  shoulder  and  arm. 


A  TELECTA8IS.  36 1 

ATELECTASIS. 

(a)  Areas  of  atelectasis  or  collapse  of  pulmonary  tissue  are 
often  present  in  connection  with  various  pathological  processes  in 
the  lung  (such  as  tuberculosis  or  lobular  pneumonia),  but  are  usu- 
ally too  small  to  give  rise  to  any  characteristic  physical  signs; 
nevertheless 

(£)  In  most  normal  individuals  a  certain  degree  of  atelectasis 
of  the  margins  of  the  lungs  may  be  demonstrated  in  the  following 
way :  The  position  of  the  margins  of  the  lungs  in  the  axillae,  in  the 
back,  or  in  the  precordial  region  are  marked  out  by  percussion  at  the 
end  of  expiration.  The  patient  is  then  directed  to  take  ten  full 
breaths,  and  the  pulmonary  outlines  at  the  end  of  expiration  are 
then  percussed  out  a  second  time.  The  pulmonary  resonance  will 
now  be  found  to  extend  nearly  an  inch  beyond  its  former  limits, 
owing  to  the  distention  of  previously  collapsed  air  vesicles. 

If  one  auscults  the  suspected  areas  during  the  deep  breaths 
which  are  used  to  dispel  the  atelectasis,  very  fine  rales  are  often 
to  be  heard  at  the  end  of  expiration,  disappearing  after  a  few 
breaths  in  most  cases,  but  sometimes  audible  as  long  as  we  choose 
to  listen  to  them.  These  sounds,  to  which  Abrams  has  given  the 
name  of  "atelectatic  crepitation,"  are  in  my  experience  especially 
frequent  at  the  base  of  either  axilla.  The  same  writer  has  noticed 
an  opacity  to  the  ce-rays  over  such  atelectatic  areas. 

Forcible  percussion  may  be  sufficient  to  distend  small  areas  of 
collapsed  lung,  or  at  any  rate  to  dispel  the  dulness  previously  pres- 
ent (see  above,  p.  136,  the  lung  reflex). 

(c)  When  one  of  the  large  bronchi  is  compressed  (as  by  an 
aneurism)  or  occluded  by  a  foreign  body,  collapse  of  the  corre- 
sponding area  of  lung  may  be  shown  by  diminished  motion  of  the 
affected  side,  dulness  on  percussion,  and  absence  of  breathing,  voice 
sounds,  and  tactile  fremitus. 

In  new-born  babies  whose  lungs  do  not  fully  expand  at  the  time 
of  birth,  similar  physical  signs  are  present  over  the  non-expanded 
lobes.  The  right  lung  is  especially  apt  to  be  affected 

In  the  differential  diagnosis  of  extensive  pulmonary  collapse, 


362  PHYSICAL   DIAGNOSIS. 

the  etiology,  the  suddenness  of  the  onset,  the  absence  of  fever  and 
of  displacement  of  neighboring  organs  enable  us  to  exclude  pneu- 
monia and  pleuritic  effusion.  In  distinguishing  small  areas  of 
solidification  from  similar  areas  of  atelectasis,  Abrams  finds  the 
"lung-reflex"  (see  page  136)  of  value.  Atelectatic  areas  expand 
if  the  skin  overlying  them  is  irritated.  Solidified  areas  show  no 
change. 

(EDEMA  OP  THE  LUNGS. 

In  cardiac  or  renal  disease  one  can  often  demonstrate  that  the 
lungs  have  been  invaded  by  transuded  serum  as  a  part  of  the  gen- 
eral dropsy.  More  rarely  pulmonary  O3dema  exists  without  much 
evidence  of  oedema  in  other  organs  or  tissues. 

The  only  physical  sign  characteristic  of  this  condition  is  the 
presence  of  numerous  r&les  in  the  dependent  portions  of  the  lungs; 
that  is,  throughout  their  posterior  surfaces  when  the  patient  has 
been  for  some  time  in  a  recumbent  position ;  or  over  the  lower  por- 
tions of  the  axillae  and  the  back  if  the  patient  has  not  taken  to 
his  bed. 

The  rales  are  always  bilateral  (unless  the  patient  has  been  lying 
for  a  long  time  on  one  side),  and  the  individual  bubbles  appear  to 
be  all  of  the  same  size,  or  nearly  so,  differing  in  this  respect  from 
those  to  be  heard  in  bronchitis.  Squeaking  or  groaning  sounds  are 
less  of  ten  heard.  The  respiratory  murmur  is  usually  somewhat;  di- 
minished in  intensity. 

Dulness  on  percussion  and  modification  of  voice  sounds  are  not 
present,  unless  hydrothorax  or  hypostatic  pneumonia  complicate 
the  oedema. 

HYPOSTATIC  PNEUMONIA. 

In  long,  debilitating  illness,  such  as  typhoid  fever,  the  alveoli 
of  the  dependent  portions  of  the  lungs  may  become  so  engorged 
with  blood  and  alveolar  cells  as  to  be  practically  solidified.  Under 
these  conditions  examination  of  the  posterior  portions  of  the  lungs 
shows  usually : 

(a)  Slight  dulness    on    percussion  reaching  usually  from  the 


HYPOSTATIC  CONGESTION.  363 

base  to  a  point  about  one-third  way  up  the  scapula.  At  the  very 
base  the  dulness  is  less  marked  and  becomes  mixed  with  a  shade  of 
tympany. 

(b)  Feeble  or  absent  tactile  fremitus. 

(c)  Diminished  or  suppressed  breathing  and  voice  sounds. 

The  right  lung  is  apt  to  be  more  extensively  affected  than 
the  left. 

Occasionally  the  breathing  is  tubular  and  the  voice  sounds  are  in- 
creased, making  the  physical  signs  identical  with  those  of  croupous 
pneumonia,  but  as  a  rule  the  bronchi  are  as  much  engorged  as  the 
alveoli  to  which  they  lead,  and  hence  no  breath  sounds  are  pro- 
duced. 

Rales  of  cedema  or  of  bronchitis  may  be  present  in  the  adjacent 
parts  of  the  lungs.  The  fact  that  the  dulness  is  less  marked  at  the 
base  of  the  lung  than  higher  up  helps  to  distinguish  the  condition 
from  hydro  thorax. 

The  diagnosis  is  usually  easy,  owing  to  the  presence  of  the  un- 
derlying disease.  Fever,  pain,  and  cough  such  as  characterize 
croupous  pneumonia  are  usually  absent. 


CHAPTER  XVIII. 

THE   ABDOMEN   IN   GENERAL,   THE   BELLY  WALLS, 
PERITONEUM,   OMENTUM,   AND   MESENTERY. 

EXAMINATION  OF  THE  ABDOMEN  IN  GENERAL. 

OUR  methods  are  crude  and  inexact  compared  to  those  applica- 
ble to  the  chest.  Auscultation  is  of  practically  no  use.  Inspec- 
tion is  helpful  in  but  few  cases.  Palpation,  our  mainstay,  is  often 
rendered  almost  impossible  by  thickness,  muscular  spasm,  or  ticklish- 
ness  of  the  abdominal  walls.  Percussion  is  of  great  value  in  some 
cases,  but  yields  no  useful  results  in  the  majority. 

Technique. — The  knack  of  abdominal  examination,  and  especially 
that  part  of  it  whereby  the  skilled  diagnostician  gets  his  most  val- 
ued information,  is  difficult  even  to  demonstrate  and  almost  impos- 
sible to  describe.  Hence  the  account  of  it  in  this  and  other  books 
is  very  brief  when  compared  with  the  space  allotted  to  the  methods 
of  examining  the  chest.1 

The  table  or  bed  on  which  the  patient  lies  during  most  abdomi- 
nal examinations  (excluding  gynaecological  work)  should  be  at  least 
three  feet  high,  narrow,  and  firm.  Most  beds  are  too  low,  too 
wide,  and  too  soft ;  but,  on  the  other  hand,  the  patient  must  not  be 
made  uncomfortable  by  the  hardness  or  coldness  of  the  surface  on 
which  he  lies.  A  comfortable  pillow  should  be  provided. 

1 1  have  heard  a  physician  in  a  leading  American  city  say  that  when  pal- 
pation of  the  spleen  in  typhoid  fever  was  first  introduced,  there  was  but  one 
physician  in  the  city  who  had  the  knack,  and  that  his  colleagues  were  very 
sceptical  about  the  possibility  of  accomplishing  the  feat  at  all.  I  have  seen  a 
similar  uncertainty  regarding  the  palpation  of  the  normal  but  slightly  dis- 
placed right  kidney. 


THE  ABDOMEN  IN  GENERAL.  365 

INSPECTION.— We  need  a  tangential  light,  such  as  accentuates 
by  shadows  every  unevenness  of  the  surface.  If  the  patient  is  ex- 
amined in  the  ordinary  dorsal  decubitus,  the  light  from  any  single 
window,  except  one  overhead,  is  satisfactory.  If  one  inspects  the 
abdomen  with  the  patient  upright,  he  should  stand  with  his  side  to 
the  light,  not  facing  it.  By  inspection  we  seek  information  on : 

(a)  The  general  contour  of  the  abdomen. 

(#)  The  surface  of  the  belly  walls,  especially  the  skin  and  the 
navel* 

(c)  Respiratory  movements,  their  limitation  or  absence. 

(rf)  Peristaltic  movements  (gastric  or  intestinal  in  origin). 

(e)  The  presence  of  local  prominence  or  (rarely)  depression. 

Inspection  of  the  Belly  Wall. — 1.  The  surface  of  the  belly  wall  is 
often  searched  most  carefully  for  the  rose  spots  of  typhoid  fever, 
which  are  hypersemic,  very  slightly  elevated  spots,  about  the  diam- 
eter of  a  large  pin  head  (2-4  mm.).  They  disappear  on  pressure. 
Pimples  are  usually  larger,  better  defined  at  the  edges,  and  more 
highly  colored,  contrasting  with  the  very  pale  red  of  most  rose 
spots.  They  are  by  no  means  confined  to  the  belly  and  may  be 
found  exclusively  on  the  back.  Having  been  at  the  outset  some- 
what sceptical  of  their  value  in  diagnosis,  I  have  become  thoroughly 
convinced  by  greater  experience  and  more  careful  examination. 
The  spots  are  present  in  about  three-fourths  of  all  cases,  and,  while 
they  also  may  occur  in  any  disease  when  the  blood  contains  bacteria 
(e.g. ,  sepsis),  they  are  commonest  in  typhoid. 

2.  Distended  and  tortuous  veins  on  the  abdomen  are  seen  in  dis- 
eases obstructing  the  portal  circulation  (rarely  in  cirrhotic  liver)  or 
the  inferior  cava  (see  Fig.  60). 

3.  Striae,  or  linear  markings  on  the  skin  of  the  abdomen,  follow 
any  long-standing  trouble  that  stretches  the  skin — pregnancy,  obes- 
ity, tumors,   etc.       They  are  red  when  first  produced,  but  later 
turn  white  (linece  albicantes). 

4.  Scars  of  old  wounds  or  operations  may  be  of  great  diagnostic 
value  in  comatose  or  delirious  cases. 

5.  Projection  or  levelling  of  the  normal  depression  at  the  navel 
is  evidence  of  distention  within  the  belly. 


366  PHYSICAL  DIAGNOSIS. 

Respiratory  movements  of  the  belly  walls  are  limited  or  cease  in 
painful  diseases  within  the  peritoneum  (peritonitis,  lead  colic)  or 
when  the  diaphragm  is  pushed  up  by  a  large  tumor,  ascites,  or  mete- 
orism. 

Peristaltic  waves  creeping  along  beneath  the  belly  walls  are 
seen  with  chronic  stenosis  and  obstruction  at  the  pylorus  or  at  some 
point  in  the  colon  and  occasionally  in  thin  but  healthy  persons. 

Hernia?  and  local  and  general  prominences  will  be  discussed  in 
connection  with  abdominal  tumors  (page  370). 

PALPATION.' — With  the  patient  on  the  back  upon  a  suitable  bed 
or  table,*  the  head  on  a  comfortable  pillow,  and  the  abdomen  ex 
posed,  run  the  palrn  of  the  hand  (warm)  lightly  over  the  whole  sur- 
face, to  accustom  the  muscles  to  its  presence.  Then  try  whether 
better  relaxation  of  the  belly  walls  is  obtained  when  the  patient's 
knees  are  drawn  up.  Some  patients  relax  better  in  this  position ; 
others  when  the  legs  are  extended. 

If  the  muscles  of  the  abdomen  remain  contracted  and  stiff  even 
when  the  patient  is  comfortable  and  has  become  accustomed  to  the 
presence  of  the  physician's  hand,  we  may  try  to  induce  relaxation : 

(a)  By  getting  the  patient  to  take  a  series  of  deep  breaths. 

(6)  By  diverting  his  attention  through  conversation  or  other- 
wise. 

If  these  means  fail  and  it  is  important  that  we  should  thoroughly 
investigate  the  abdomen,  we  have  left  two  further  ways  of  produc- 
ing relaxation,  viz. : 

(c)  By  putting  the  patient  into  a  warm  bath. 

(d)  By  anaesthesia  (ether  or  chloroform). 

The  movements  of  the  physician's  hand  should  never  be  sudden 
or  rough.  He  should  avoid  digging  into  the  skin  with  his  nails  or 
pressing  strongly  on  a  small  spot  with  the  finger-tips.  If  any  spot 

1  Special  methods  of  palpating  a  diseased  kidney,  spleen,  or  liver  are  de- 
scribed in  the  sections  on  those  organs. 

1  It  is  essential  that  the  physician  as  well  as  the  patient  should  be  comfort- 
able during  an  abdominal  examination,  else  his  attention  is  not  wholly  on  his 
work.  Hence  the  importance  of  a  high,  narrow  bed,  or  table,  so  that  the 
physician  need  not  stretch  or  stoop  to  reach  the  patient. 


THE  ABDOMEN  IN  GENERAL.  367 

be  suspected  to  be  tender,  that  should  be  palpated  last,  after  going 
over  the  rest  of  the  abdomen.  If  it  is  necessary  to  make  deep 
pressure  at  any  point,  it  is  best  to  lay  the  fingers  of  the  left  hand 
loosely  over  the  spot  and  then  exert  pressure  upon  them  with  the 
fingers  of  the  right  hand.  The  passive  hand  is  more  sensitive.  To 
reach  a  deep  spot,  put  the  hands  in  this  position  over  it,  ask  the 
patient  to  take  a  long  breath,  and,  as  the  belly  falls  in  expiration, 
follow  it  down  with  the  hands.  Then  hold  what  you  have  gained, 
and  with  the  next  full  expiration  you  may  be  able  to  get  in  still 
deeper,  until  after  a  series  of  deep  breaths  the  desired  spot  is 
reached.  Naturally  this  cannot  be  done  if  there  is  much  tender- 
ness, but  pure  nervous  spasm  may  sometimes  be  overcome  in  this 
way. 

To  make  use  of  the  relaxation  secured  by  a  hot  bath,  we  need 
an  unusually  long  tub,  so  that  the  patient  can  lie  almost  flat  when 
his  knees  are  slightly  drawn  up.  If  he  is  doubled  up  with  his 
knees  and  head  in  close  proximity,  nothing  can  be  accomplished. 
The  patient  gets  into  the  tub  with  the  water  comfortably  warm,  and 
its  temperature  is  then  raised  to  between  110°  and  120°  F.  by  pour- 
ing in  very  hot  water.  The  greatest  relaxation  is  usually  attained 
after  about  ten  minutes'  immersion. 

This  method  is  far  less  inconvenient  than  etherization  and  is 
especially  valuable  when  the  recti  are  well  developed  and  form 
rounded,  tumor-like  masses  as  soon  as  ordinary  palpation  is  at- 
tempted. If  we  suspect  that  a  tumor-like  mass  may  be  one  of  the 
bellies  of  the  rectus,  it  is  well  to  grasp  the  mass  with  the  hand  and 
then  ask  the  patient  to  raise  his  head.  The  mass  will  harden  sud- 
denly if  it  is  the  rectus. 

What  can  be  Felt  Beneath  the  Normal  Abdominal  Walh. 

No  part  of  the  normal  intestine,  including  the  appendix,  can, 
in  my  opinion,  be  felt  through  the  abdominal  walls.  The  same  is 
true  of  the  stomach,  spleen,  left  kidney,  pancreas,1  bladder,  and 

1  Leube  believes  that  in  very  thin  subjects  the  head  of  the  pancreas  may 
occasionally  be  felt. 


368  PHYSICAL  DIAGNOSIS. 

pelvic  organs.      All  that  we  can  make  out  in  most  normal  cases 
is: 

1.  The  abdominal  aorta. 

2.  The  spinal  column,  near  and  above  the  umbilicus. 

3.  Part  of  the  liver  (occasionally,  if  the  costal  angle  is  sharp  and 
the  belly  walls  are  thin  and  lax). 

4.  The  tip  of  the  right  kidney  (in  many  young  persons). 

5.  Gurgling  and  splashing  in  the  stomach  or  colon. 

The  aorta  is  too  deep  to  be  felt  at  all  in  some  persons,  but,  on 
the  other  hand,  it  is  astonishing  now  close  under  the  belly  wall  it  is 
in  others,  i.e.,  in  those  whose  dorsal  spine  projects  sharply  for- 
ward. In  such  persons  the  aorta  may  be  almost  taken  in  the  hand, 
and  its  course,  calibre,  and  motions  are  so  startlingly  evident  that 
it  is  often  mistakenly  supposed  to  be  the  seat  of  an  aneurism  (see 
above,  page  280),  especially  as  a  systolic  murmur  and  thrill  can  be 
appreciated  over  it  if  a  little  pressure  is  exerted,  so  as  to  produce 
an  artificial  stenosis. 

Behind  and  beside  the  aorta  we  can  sometimes  feel  the  bodies  of 
the  vertebrae,  and  on  them  trace  the  division  of  the  aorta  into  the 
common  iliacs. 

The  liver  cannot  be  felt  at  all  in  the  great  majority  of  normal 
persons,  but  occasionally  the  costal  angle  is  so  sharp  that  a  small 
portion  of  the  organ  is  palpable  in  the  epigastric  region. 

Bimanually  (see  below,  page  417)  the  tip  of  the  normal  right 
kidney  may  often  be  caught  between  the  hands  at  the  end  of  a 
long  inspiration,  especially  in  young,  thin  people  with  lax  belly 
walls. 

If  the  stomach  or  colon  contains  fluids,  the  palpating  hand  often 
elicits  sounds  corresponding  to  the  movement  of  these  fluids.  Their 
only  importance  in  diagnosis  will  be  mentioned  on  page  378. 

The  ilio-psoas  muscle  can  occasionally  be  felt  deep  in  the  iliac 
region. 

Very  deceptive  often  are  muscular  bundles  in  the  external 
oblique,  which  seem  distinguishable  as  sausage-shaped  tumors,  and 
doubtless  give  rise  to  some  of  the  legends  about  feeling  the  nor- 
mal appendix. 


THE  ABDOMEN  IN  GENERAL. 


369 


Palpable  Lesion  of  the  Belly  Walls. 

The  occurrence  of  lesions,  to  be  recognized  mainly  by  inspection 
and  percussion,  has  been  discussed  (page  365).  Besides  these  we 
search  for : 

1.  Hernia>,  epigastric  or  umbilical  (see  Fig.  179).     The  diagnosis 
rests  on  the  presence  of  an  impulse  on  coughing,  with  or  without  a 
reducible  tumor.     Omental  hernias  do  not  bulge  with  cough. 

2.  Separation  of  the  Recti. — When    the    patient,   lying  on   the 
back,  lifts  his  head  and  shoulders,  a  longitudinal  wedge  bulges  out 


FIG.  179.— Epigastric  Hernia. 

along  the  median  line  of  the  belly  from  the  gastric  to  the  suprapu- 
bic  region. 

3.  Abscess  of  the  abdominal  walls  usually  represents  a  stitch  ab- 
scess or  the  external  vent  of  pus  burrowing  from  the  appendix,  the 
pelvis,   or  the  prevesical  space.      But  in  about  one-third  of  the 
cases  no  such  cause  can  be  found.     An  infected  hsematoma  due  to 
trauma  or  without  known  cause  explains  some  cases,  and  occasion- 
ally tuberculosis   or  actinomycosis  occurs.     The  latter  conditions 
are  recognized  by  the  microscopic  examination  of  the  pus  and  of  the 
abscess  wall. 

4.  Sarcoma  of  the  belly  wall  is  rather  rare,  and  can  be  recog- 
nized with  certainty  only  by  microscopic  examination ;  without  this 
I  have  known  it  to  be  confused  with  lipoma  and  with  tuberculosis. 

24 


370  PHYSICAL  DIAGNOSIS. 

5.  Thickening  or  inflammation  at  the  navel  occurs  in  some  cases 
of  cancerous  or  tuberculous  peritonitis.  The  diagnosis  rests  on  the 
farther  evidence  of  cancer  or  tuberculosis  within  the  peritoneal  cav- 
ity and  on  the  microscopic  examination  of  a  piece  excised  for  the 
purpose. 

Palpation  of  the  Spleen  (see  page  413). 

Palpation  of  the  Liver  (see  page  388). 

Palpation  of  the  Kidney  (see  page  417). 

Study  of  Abdominal  Tumors. 

One  should  notice :  Size,  contour,  consistency,  mobility  with  press- 
ure and  with  respiration,  tenderness,  pulsation,  peritoneal  crepitus, 
adherence  to  the  skin  or  to  the  abdominal  wall,  relationship  to  any 
abdominal  organ  (also  dulness  or  resonance  on  percussion,  see  below, 
page  372). 

Most  of  these  points  need  no  comment.  To  ascertain  whether 
the  tumor  involves  the  skin,  one  lifts  up  a  fold  of  skin  crossing  the 
mass.  If  the  skin  dimples  markedly  over  the  tumor,  i.e.,  fails  to 
rise  at  that  point  while  on  all  sides  of  the  mass  it  can  easily  be 
picked  up,  the  skin  is  adherent.  Tumors  in  the  abdominal  wall 
can  usually  be  gathered  up  along  with  the  latter  when  we  grasp  a 
large  fold  with  both  hands. 

To  determine  the  relationship  of  a  tumor  with  the  liver  or  spleen 
we  note : 

(a)  Whether  a  groove  or  interval  can  be  made  out,  by  palpation 
or  percussion,  between  the  mass  and  either  of  those  organs. 

(b)  Whether  its  respiratory  mobility  is  as  great  as  theirs. 

(c)  Whether  there  are  other  facts  in  the  case  suggestive  of  he- 
patic or  splenic  disease  (jaundice,  ascites,  leukaemic  blood). 

(d)  The  effect  of  inflation  of  the  colon  (see  below).     Tumors 
connected  with  the  spleen  are  forced  forward  and  do  not  become 
resonant  when  the  colon  is  inflated. 

To  determine  the  degree  of  respiratory  mobility,  hold  the  fingers 
of  one  hand  in  contact  with  the  lower  edge  of  the  mass  and  allow 
them  to  descend  with  it  while  the  patient  takes  a  full  breath.  To 


THE  ABDOMEN  IN  GENERAL.  371 

make  sure  that  an  actual  descent  occurs,  one  must  sight  the  mass 
(and  the  hand)  against  some  motionless  object  in  the  room  beyond, 
else  one  may  be  deceived  by  the  movement  of  the  abdominal  walls 
over  the  tumor,  while  the  tumor  itself  remains  motionless  or  nearly 
so.  Tumors  connected  with  the  liver  or  spleen  move  about  two 
inches  with  a  forced  inspiration.  Kidney  tumors  move  less,  seldom 
as  much  as  an  inch.  Pancreatic  and  retroperitoneal  tumors  have 
scarcely  any  mobility.  Those  connected  with  the  intestine  vary 
considerably  in  respiratory  mobility,  according  to  the  presence  and 
degree  of  adherence  to  other  parts,  but  their  excursion  is  rarely  an 
inch. 

Peritoneal  crepitus  is  a  grating,  rubbing  sensation  experienced 
on  light  palpation,  and  due — supposedly — to  the  presence  of  a 
plastic,  peritoneal  exudate  similar  to  that  which  produces  the 
friction  sounds  in  pericarditis.  Over  an  enlarged  spleen  (e.g.,  in 
leukaemia)  peritoneal  crepitus  may  be  due  to  local  perisplenitis,  and 
in  perigastritis,  perihepatitis,  and  perienteritis  similar  crepitus 
occurs. 

Dipping  refers  to  a  sudden  displacement  of  the  abdominal  wall 
and  whatever  lies  close  beneath  it,  by  a  swift  poke  of  the  finger 
tips,  which  may  succeed  thereby  in  touching  a  solid  organ  or  tumor 
which  gentle,  gradual  palpation  misses.  Thus  one  may  reach  and 
mark  out  an  enlarged  liver  through  a  layer  of  ascites  which  would 
prevent  ordinary  palpation. 

PERCUSSION. — Abdominal  percussion  is  less  valuable  than  tho- 
racic. A  lighter  blow  is  used,  and  the  distinction  between  dulness 
and  tympany  is  easy.  It  is  of  value  chiefly  to  determine  the  pres- 
ence of  fluid  free  in  the  peritoneal  cavity,  and  to  ascertain  whether 
a  tumor  is  due  to  or  covered  by  gaseous  distention. 

(a)  Free  fluid  (ascites,  peritonitis,  hsemoperitoneum,  ruptured 
cyst)  gravitates  to  the  flanks  and  suprapubic  region,  while  the  in- 
testines float  up  and  occupy  the  epigastric  and  umbilical  space. 
Hence  there  is  dulness  in  the  flanks  and  over  the  pubes,  with  reso- 
nance in  the  epigastric  and  umbilical  regions.  But  the  crucial  and 
ever-necessary  test  is  the  shifting  of  this  area  of  dulness  when  the 
patient  turns  on  his  side ;  then  the  uppermost  flank  should  become 


372  PHYSICAL  DIAGNOSIS. 

resonant  and  the  lower  half  of  the  belly — including  part  of  the 
umbilical  region — dull.  Without  this  test  the  mere  marking  out  of 
dull  areas  in  the  flanks  is  not  conclusive  evidence  of  free  fluid  there. 
Still  less  reliable  is  the  "fluctuation  wave,"  which  can  be  trans- 
mitted as  an  impulse  palpable  to  the  hand  laid  flat  on  one  flank, 
by  sharply  snapping  the  other  flank.  Similar  impulses  can  be  trans- 
mitted through  the  fat  of  the  belly  wall,  despite  all  efforts  to  check 
them  by  pressure  upon  the  latter. 

(&)  Percussion  is  our  final  test  in  the  diagnostic  procedure  that 
begins  with  inflation  of  the  colon.  Air  is  forced  into  the  rectum 
with  an  ordinary  Davidson  syringe,  and,  as  the  colon  becomes 
prominent  and  hyperresonant,  we  note  whether  its  tympany  covers 
up  the  tumor-mass  under  investigation  or  whether  the  mass  lies  an- 
terior to  and  remains  dull  over  the  inflated  colon.  Kidney  tumors 
lie  behind  the  inflated  colon;  splenic  tumors  remain  dull  in  front 
of  it. 

Auscultatory  percussion,  for  identification  or  deniarkation  of  ab- 
dominal tumors  and  organs,  has  never  been  successful  in  my  hands 
nor  in  those  of  most  of  the  observers  in  whose  results  I  have  confi- 
dence. Hence  I  omit  further  description  of  it. 

Percussion  of  the  stomach  and  spleen  (see  below,  pages  380  and 
412). 

Percussion  of  Traube 's  semilunar  tympanitic  space  (the  small 
area  bounded  on  the  right  by  the  splenic  and  on  the  left  by  the  he- 
patic dulness,  above  by  the  free  edge  of  the  left  lung,  and  below  by 
the  lower  edge  of  the  ribs)  is,  in  my  experience,  of  very  little  value 
in  diagnosis.  This  tympanitic  area  is  obliterated  in  many  pleuritic 
effusions  (not  in  all),  but  many  other  causes  (full  stomach  or  gut, 
obese  omentum)  may  produce  similar  dulness. 


DISEASES  OF  THE  PERITONEUM. 

1.  Peritonitis — local  or  general. 

2.  Ascites. 

3.  Cancer  and  tuberculosis. 


THE  ABDOMEN  IN  GENERAL.  373 


/.  Peritonitis. 

1.  Local  peritonitis  gives  evidence  of  its  presence  by  (a)  pain, 
(#)  tenderness,  (c)  muscular  spasm,  (d~)  tumor,  and  (e)  constitu- 
tional manifestations. 

The  pain  may  be  at  first  diffuse,  later  localizing  itself  at  the  site 
of  the  lesion ;  or  it  may  be  felt  first  where  the  peritonitis  begins  and 
spread  with  the  lesion  if  the  general  peritoneal  cavity  become  in- 
volved. The  character  and  intensity  of  the  pain  vary  greatly. 

Tenderness  is  the  important  sign  in  diagnosis,  and  helps  us  to 
exclude  the  various  colics  and  other  causes  of  pain  which  are  often 
relieved  by  pressure. 

Local  muscular  spasm  of  the  belly  muscles  to  guard  the  tender 
lesion  beneath  is  of  great  value  in  pointing  our  attention  to  the  spot 
affected,  though  the  muscles  may  be  so  rigid  as  to  prevent  palpa- 
tion through  them.  [Psoas  spasm  is  described  in  the  section  on 
appendicitis,  see  page  402.] 

The  tumor  is  apt  to  consist  of  intestine  or  other  organs  matted 
together  by  adhesions  about  the  site  of  the  process. 

The  constitutional  manifestations  are  those  of  infection,  viz., 
fever,  leucocytosis,  anorexia,  constipation,  often  albuminuria  and 
albumosuria. 

The  commonest  causes  of  local  peritonitis  are : 

1.  Appendicitis. 

2.  Pus  tube. 

3.  Gall-bladder  inflammation. 

Less  common  is  cancer  or  ulcer  of  the  stomach  or  intestine. 

2.  General  Peritonitis. — The  belly  may  be  generally  swollen  and 
tympanitic  or  retracted  and  hard.  General  tenderness  is  the  most 
important  sign.  In  advanced  cases  free  fluid  in  the  flanks  may  be 
demonstrated,  as  explained  on  page  371.  Faeces  and  even  gas  cease 
to  move,  as  the  intestines  are  paralyzed.  Vomiting  is  the  rule,  and 
soon  becomes  very  foul  (stercoraceous).  There  is  fever,  with  a 
rapid  and  very  weak  pulse.  The  mind  is  clear,  alert.  The  facial 
expression  is  not  peculiar  and  may  be  normal.  If  there  is  persis- 


374  PHYSICAL  DIAGNOSIS. 

tent  vomiting  the  facies  of  that  condition  appears,  viz.,  a  drawn, 
pinched,  anxious  look,  with  dark  circles  under  the  eyes.  The  nau- 
sea and  the  rapid  loss  of  fluid  by  vomiting  account  for  these  ap- 
pearances. 

The  leucocyte  count  is  generally  elevated,  but  in  the  most 
virulent  cases  remains  normal  or  sub- 
normal. 

77.  Ascites. 

The  commonest  causes  are : 

(1)  Portal  stasis,  usually  from  cir- 
rhosis of  the  liver. 

(2)  Dropsy,  from  cardiac,   pericar- 
dial,  or  renal  disease. 

(3)  Tuberculous  peritonitis. 

(4)  Anaemia. 

(5)  Cancer  of  the  peritoneum. 

(6)  Solid  ovarian  tumors. 

The  methods  of  diagnosis  of  ascites 
have  been  explained  above.  The  diag- 

FIG.  m-cha^teri^shape  of  nosig  of  itg  ^^  depends  on  the  his- 
tory, the  results  of  puncture,  and  the 

general  physical  examination.     The  contour  of  the  belly  is  often 

that  pictured  in  Fig.  180. 

777.    Cancer  and  Tuberculosis  of  the  Peritoneum. 

In  connection  with  cancer  or  tuberculosis  of  some  abdominal  or 
pelvic  organ,  the  disease  may  become  spread  throughout  the  perito- 
neum with  deposits  in  the  omentum  and  mesentery.  The  signs 
are :  1.  Tumor  masses  scattered  here  and  there,  sometimes  at  the 
navel.  2.  Ascites.  3.  Emaciation  and  anaemia. 

The  diagnosis  of  cancer  depends  on  the  recognition  of  multiple, 
hard,  nodular  tumors  in  the  abdomen  of  a  patient  known  to  have 
cancer  of  some  abdominal  organ. 

Somewhat    similar  masses,   usually  due  to    loops  of  intestine 


THE  ABDOMEN  IN  GENERAL.  375 

matted  together  by  adhesions,  may  be  felt  in  tuberculous  peritonitis, 
but  here  they  are  larger,  fewer,  and  not  so  hard.  Cancer  appears 
in  late  life,  tuberculous  peritonitis  usually  in  early  life.  The  ema- 
ciation and  ansemia  are  less  marked  in  tuberculosis,  and  fever  is 
more  marked.  The  history  or  present  evidence  of  tuberculosis  else- 
where— lung,  pleura,  glands,  pelvis,  testis — favors  the  diagnosis  of 
tuberculous  peritonitis.  Cytodiagnosis  and  the  tuberculin  test  may 
be  of  value  in  diagnosis. 

THE  MESENTEKY. 

1.  Enlarged   glands  —  tuberculous,    cancerous,    or    as   part   of 
Hodgkin's  disease — can  occasionally  be  felt  in  very  thin  patients. 
Their  recognition  as  glands  would  depend  on  more  obvious  evidence 
of  their  cause  in  other  parts  of  the  body. 

2.  Mesenteric  thrombosis  produces  all  the  signs  of  intestinal  ob- 
struction (see  below,  page  403),  from  which  it  can  rarely  if  ever  be 
distinguished  without  operation  or  autopsy. 


CHAPTER   XIX. 

THE   STOMACH,    LIVER,    AND   PANCREAS. 
THE  STOMACH. 

THE  best  methods  of  examining  the  stomach  are : 

1.  Inspection  and  palpation  of  the  epigastrium  and  the  neigh- 
boring portions  of  the  abdomen. 

2  Estimation  of  the  size  and  position  of  the  organ  after  dis- 
tending it  with  air  or  water. 

3.  Examination  of  the  stomach  contents :  (a)  fasting ;  (b)  after 
a  test  meal. 

By  combining  the  results  of  these  three  methods  of  examination 
with  the  results  of  our  general  examination  of  the  body — emacia- 
tion, anaemia,  etc. — and  with  the  data  obtained  by  a  careful  history, 
we  obtain  all  the  information  about  the  stomach  which  it  is  possible 
for  us  to  make  use  of  at  the  present  time. 

1.   Inspection  and  Palpation  of  the  Epigastrium. 

(a)  Tenderness. — The  normal  stomach  cannot  be  seen  or  felt, 
nor  can  anything  certain  be  learned  in  regard  to  it  by  percussion  or 
auscultation.  Tenderness  in  the  epigastrium  is  so  common  that  we 
can  attach  no  significance  to  it  unless  it  is  extreme  and  sharply  lo- 
calized in  a  small  area.  Extreme  localized  tenderness  is  of  a  cer- 
tain amount  of  value  in  connection  with  the  diagnosis  of  gastric 
ulcer,  but  is  by  no  means  pathognomonic  of  it.  In  a  small  propor- 
tion of  cases  cutaneous  tenderness  in  the  back  (lower  dorsal  or 
upper  lumbar  region)  can  be  elicited  in  cases  of  gastric  ulcer. 


T&E  STOMACH,    LIVER,    AND   PANCREAS. 


377 


(b)  A  tumor  in  the  epigastrium  (see  Fig.  181)  is  of  far  greater 
importance  than  any  other  local  evidence.  If  it  occurs  in  an  emaci- 
ated and  anaemic  person  past  middle  life,  is  hard  and  nodular,  and 
does  not  disappear  after  catharsis,  it  is  almost  invariably  due  to 
cancer  of  the  stomach.  In  a  young  person  such  a  tumor  may  be 
due  to  a  mass  of  adhesions  about  a  gastric  ulcer.  Tumors  of  the 
pancreas  much  less  often  reach  the  surface  in  this  region ;  tumors 
of  the  liver  are  generally  larger,  and  their  connection  with  this  or- 


FIG.  181.— Epigastric  Tumor  in  Gastric  Cancer. 

gan  can  generally  be  demonstrated  by  percussion,  palpation,  and 
by  their  greater  respiratory  mobility  when  compared  with  gastric 
cancer. 

Epigastric  hernia  usually  shows  an  impulse  on  coughing,  is  soft 
and  doughy  in  feel,  and  presents  none  of  the  other  symptoms  and 
signs  of  gastric  cancer. 

Tubercular  deposits  in  the  omentum  are  almost  always  associ- 
ated with  ascites,  fever,  and  other  evidences  of  tuberculosis  either 
in  the  examination  of  other  organs  or  in  the  history. 

(c)  Visible  gastric  peristalsis  means  stenosis  of  the  pylorus  (can- 
cer, cicatrix,  adhesions,  simple  thickening,  or  muscular  spasm). 
The  contraction  wave  passes  from  left  to  right  across  the  epigas- 
trium, and  is  seen  by  means  of  the  shadow  cast  by  a  tangential 
light  with  the  patient  in  a  recumbent  position.  If  the  peristalsis 


378 


PHYSICAL  DIAGNOSIS. 


stops  it  can  sometimes  be  reexcited  by  briskly  snapping  the  epigas- 
tric region  with  the  finger. 

(d)  The  normal  splash  sound  can  usually  be  heard  if  sudden, 
quick  pressure  is  made  in  the  epigastrium  within  three  hours  after 
a  meal.  If  splashing  can  be  elicited  more  than  three  hours  after  a 

meal,  and  especially  if  it  is 
present  before  breakfast,  it  is 
evidence  of  gastric  stasis  and 
usually  of  dilatation. 

(e)  Hypogastric  bulging  due 
to  dilated  stomach  is  occasion- 
ally seen  in  cases  of  marked 
dilatation  when  the  patient 
stands  up,  and  is  examined  in 
profile  (see  Fig.  182). 


FIG.  182.— Outline  of  Abdomen  in  Dilatation  of 
the  Stomach. 


2.  Estimation  of  the  Size,  Posi- 
tion, Secretory  and  Motor 
Power  of  the  Stomach. 

Whenever  we  cannot  arrive 
at  a  satisfactory  diagnosis  by 
means  of  the  above  methods  of 
external  examination  when 
taken  in  connection  with  the 
history  and  the  general  condi- 
tion of  nutrition,  we  must  undertake  a  more  direct  investigation  of 
the  organ,  which  begins  with  («.)  the  passage  of  the  stomach  tube. 
The  standard  red  rubber  tube  generally  in  use  in  this  country 
comes  in  two  sizes.  Personally  I  prefer  the  larger,  with  a  lateral 
as  well  as  a  terminal  opening  at  the  lower  end,  although  the  smaller 
size  produces  somewhat  less  discomfort.  The  patient  should  be 
covered  by  a  rubber  sheet  and  the  clothing  removed  from  his  abdo- 
men. So  prepared,  he  should  sit  in  a  straight-backed,  wooden 
chair,  with  a  good-sized  foot-tub  between  his  feet  and  a  towel  in 


THE  STOMACH,    LIVER,    AND  PANCREAS.  379 

his  hand  ready  to  wipe  away  the  profuse  secretions  of  the  mouth 
and  pharynx.  He  should  then  be  warned  that  the  process  of  pass- 
ing a  tube,  although  entirely  free  from  danger,  is  very  disagreeable, 
both  on  account  of  the  nausea  which  it  produces  and  because  it 
often  seems  to  the  patient  as  if  he  were  choking  and  could  not  get 
his  breath.  This,  in  fact,  is  not  the  case,  and  if  the  patient  will 
persist  in  drawing  long,  deep  breaths  throughout  the  process  of 
passing  a  tube,  the  worst  of  it  is  over  in  twenty  seconds. 

The  tube  is  moistened  with  water  and  pushed  straight  down 
through  the  pharynx  without  any  attempt  to  direct  it,  beyond  keep- 
ing the  median  line.  There  is  no  danger  of  entering  the  trachea 
and  no  use  in  trying  to  avoid  it.  On  its  way  down  the  tube  is  ar- 
rested now  and  then  by  muscular  spasm  of  the  oesophagus,  but  after 
a  few  seconds  the  spasm  relaxes  and  allows  us  to  push  the  tube  on 
until  the  twenty-two-inch  mark  reaches  the  teeth.  The  lower  end 
of  the  tube  is  then  in  the  stomach,1  and  we  are  ready  to  extract  the 
gastric  contents  (in  case  a  test  meal  has  been  previously  given),  to 
wash  out  the  organ,  or  to  distend  it  with  air  or  water. 

(&)  Extracting  the  Gastric  Contents. — One  hour  after  a  test 
meal "  the  tube  is  passed  and  the  patient  is  then  asked  to  lean  for- 
ward, press  with  his  hands  upon  his  stomach,  and  strain  down  as 
if  he  were  going  to  have  a  movement  of  the  bowels.  In  most  cases 
this  suffices  to  force  the  gastric  contents  out  through  the  tube  and 
into  a  basin,  which  is  held  ready.  If  the  gastric  contents  cannot 
be  extracted  either  in  this  way  by  having  the  patient  lie  down  or  by 
moving  the  tube  in  the  pharynx  so  as  to  excite  nausea,  we  should 
make  sure  first  that  the  eye  of  the  tube  is  not  plugged.  This  may 
be  ascertained  by  disconnecting  the  funnel  and  blowing  through  the 
tube,  which  usually  suffices  to  discharge  any  obstacle  from  the  eye 
of  the  tube.  If  still  the  gastric  contents  do  not  flow  out,  we  may 
use  suction  by  connecting  a  Politzer  air-bag  with  the  end  of  the 
tube  in  place  of  the  funnel. 

'Unless  there  is  gastric  dilatation  or  gastroptosis ;  then  the  tube  must  be 
pushed  in  several  inches  farther,  the  distance  depending  on  the  position  of  the 
lower  gastric  border,  as  determined  in  previous  examinations. 

2  A  slice  of  bread  and  a  glass  and  a  half  of  water  is  a  good  test  meal. 


380  PHYSICAL  DIAGNOSIS. 

For  the  analysis  of  the  contents  so  obtained,  see  below,  page 
379. 

(c)  Distending  the  Stomach. — We  may  use  either  air  or  water. 
The  first  is  more  comfortable,  the  second  rather  more  accurate.  To 
distend  the  stomach  with  air,  disconnect  the  funnel  and  attach  a 
Davidson  syringe.  Then  have  the  patient — still  with  the  tube  in 
his  stomach — lie  down  upon  a  bed  with  the  abdomen  exposed,  and 
pump  air  rapidly  in  with  the  Davidson  syringe.  The  rapid  entrance 
of  air  causes  a  reflex  closure  of  the  pylorus  and  allows  us  to  distend 
the  stomach.  While  an  assistant  pumps  in  the  air,  we  inspect  and 
percuss  the  epigastric  region,  which  soon  begins  to  bulge  out  and 
assume  on  percussion  a  tympanitic  note  differing  clearly  in  pitch 
and  quality  from  that  obtained  in  other  portions  of  the  abdomen. 
After  a  certain  amount  of  air  has  been  pumped  in,  the  lower  border 
of  the  stomach  (as  shown  by  percussion)  ceases  to  descend,  and 
about  this  time  the  patient  begins  either  to  complain  of  pain  or  to 
belch  up  wind  around  the  tube,  showing  that  the  organ  is  fully  dis- 
tended. We  then  mark  upon  the  abdominal  wall  the  position  of  the 
lower  border  of  the  stomach,  and  if  possible  of  the  upper,  which 
can  usually  be  obtained  by  percussion. 

Position  of  the  Normal  Stomach. — The  lower  border  of  the  nor- 
mal stomach  after  air  distention  rarely  descends  below  the  level  of 
the  umbilicus;  hence  any  stomach  whose  lower  border  descends 
lower  than  this  should  be  considered  dilated,  provided  that  the 
upper  border  is  approximately  in  the  normal  situation.  If  the  up- 
per border  is  lowered  as  much  as  the  fundus,  we  are  probably  deal- 
ing with  a  case  of  gastroptosis  or  dropping  of  the  whole  organ. 

To  distend  the  stomach  with  water,  we  simply  pour  it  in 
through  the  funnel  until  the  patient  complains  of  decided  discom- 
fort and  fulness.  We  then  note  the  amount  poured  in,  let  the  fun- 
nel empty  into  a  large  foot-tub  on  the  floor,  allow  the  water  to  siphon 
out,  and  measure  the  amount  so  obtained.  The  normal  stomach 
will  hold  about  1,500  c.c.  (or  three  pints).  Anything  over  this 
amount  is  pathological.  A  difficulty  of  the  method  of  distention 
by  water  is  that  it  is  sometimes  impossible  to  get  out  of  the  stom- 
ach all  of  the  water  that  we  have  put  into  it,  whereas  with  disten- 


THE  STOMACH,    LIVER,    AND  PANCREAS.  381 

tion  with  air  there  is  no  difficulty  in  forcing  out  the  air  through 
and  around  the  tube  by  pressure  on  the  epigastrium. 

(d)  Washing  the  Stomach  (Lavarje}. — Though  not  of  much  use 
in  diagnosis,  this  procedure  may  be  briefly  mentioned  here.  After 
introducing  the  tube  as  above  described,  about  a  pint  of  water  is 
poured  in  through  the  funnel,  and,  just  before  the  water  disappears  in 
the  vortex  of  the  funnel,  the  latter  is  rapidly  lowered  so  as  to  empty 
by  siphonage  into  a  vessel  on  the  floor.  This  process  is  repeated 
until  food  and  mucus  cease  to  come  out  and  the  water  runs  clear. 

To  remove  the  tube  at  the  end  of  any  of  the  procedures  just  de- 
scribed, we  have  only  to  pinch  it  tightly  "just  outside  of  the  pa- 
tient's teeth  and  pull  it  rapidly  out. 

3.   Examination  of  Gastric  Contents. 

1.  The  contents  of  the  fasting  stomach  are  best  obtained  by  pass- 
ing the  tube  before  breakfast,  and  should  consist  of  no  more  than  a 
few  cubic  centimetres  of  clear  fluid  containing  free  hydrochloric  acid. 
If  any  food  is  present,  gastric  stasis  is  proven.     If  moro  than  50 
c.c.  of  fluid  without  food  are  present,  hypersecretion  is  indicated. 

2.  Gastric  Contents  after  a  Test  Meal. — The  best  test  meal  is 
that  of  Ewald,  and  consists  of  a  slice  of  bread  (or  its  equivalent  in 
crackers  or  cereal)  with  a  glass  and  a  half  of  water.     After  this 
meal  not  more  than  100  c.c.  should  be  found  in  the  stomach  at  the 
end  of  an  hour.     Occasionally  the  stomach  has  emptied  itself  even 
within  the  hour,  and  we  have  then  to  reduce  the  period. 

After  extracting  the  gastric  contents  as  above  described  and 
noting  the  quantity,  we  should  investigate  also  their  color,  odor, 
and  general  appearance,  (a)  Small  streaks  of  blood  are  of  no  con- 
sequence. Considerable  quantities  of  blood  (fresh)  suggest  ulcer. 
Small  quantities  of  dark-brown  substance  resembling  blood  should 
be  investigated  by  the  guaiac  test.  If  this  is  positive,  gastric  can- 
cer is  suggested. 

The  guaiac  test  is  best  performed  as  follows :  Chip  off  the  oxi- 
dized outer  shell  of  a  lump  of  gum  guaiac  and  prepare  a  fresh  tinc- 
ture by  shaking  a  few  chips  of  the  inner  non-oxidized  guaiac  with  a 
few  cubic  centimetres  of  alcohol.  Add  about  10  drops  of  this  tine- 


382  PHYSICAL  DIAGNOSIS. 

ture  and  2  c.c.  of  hydrogen  peroxide  to  an  ethereal  solution  of  the 
gastric  contents  prepared  by  extracting  10  c.c.  of  gastric  contents 
with  2  c.c.  of  glacial  acetic  acid  and  15  c.c.  of  ether  (shake  5  min- 
utes). On  adding  the  guaiac  to  the  ethereal  solution  of  gastric 
contents  a  blue  color  indicates  the  presence  of  blood. 

(i)  For  acetic  and  butyric  acids  we  test  merely  by  our  sense  of 
smell.  Whenever  stasis  or  fermentation  has  occurred,  we  are  apt 
to  get  a  characteristic  odor  of  these  acids  mingled  with  that  of  yeast. 

(c)  The  general  appearance  of  the  contents  tells  us  little  that  is 
important.  In  cases  of  marked  dilatation  they  often  separate  into 
three  layers — the  upper  frothy,  the  middle  a  thin,  turbid  liquid, 
and  the  lower  a  flocculent  sediment  of  partially  digested  food. 

Mucus  is  not  of  any  considerable  clinical  significance  unless  it 
is  so  abundant  that  the  whole  stomach  contents  will  slide  in  one 
lump  from  one  beaker  to  another. 

When  absolutely  no  digestion  has  taken  place,  as  in  the  rare 
cases  of  achylia  gastrica,  the  contents  consist  simply  of  unaltered 
bread  and  water. 

Chemical  Tests  of  Gastric  Contents. 

1.  Dip  a  piece  of  blue  litmus  in  the  contents ;  if  no  reddening 
occurs,  no  further  tests  need  be  made. 

2.  If  the  contents  are  acid  to  litmus,  test  with  Giinzburg's  re- 
agent (phloroglucin,  2  gm. ;  vanillin,  1  gin. ;  alcohol,  30  gm.),  by 
mixing  two  drops  of  it  with  an  equal  amount  of  gastric  contents  (un- 
filtered)  upon  a  white  porcelain  plate  or  dish,  and  evaporating  slowly 
over  a  flame.1     If  free  HC1  is  present,  a  bright  rose  pink  appears. 
In  the  absence  of  free  HC1,  the  color  is  a  dirty  yellowish-brown. 

If  this  test  is  positive,  we  need  make  no  further  tests  except  the 
following : 

Quantitative  Estimation  of  free  HCl  and  of  Total  Acidity. 

To  10  c.c.  of  unfiltered  gastric  contents  add  four  drops  (about) 
of  Topfer's  reagent  (dimethyl-amido-azo-benzol :  0.5  per  cent  alco- 

1  The  same  test  may  be  performed  on  a  glass  slide  which  is  subsequently 
put  upon  a  piece  of  white  paper  to  bring  out  the  color. 


THE  STOMACH,    LIVER,    AND  PANCREAS.  383 

holic  solution)  in  a  beaker ;  a  carmine-red  color  results.  Fill  a 
graduated  burette  with  decinormal  NaOH  solution,  and  let  it  run 
out  into  the  beaker,  a  few  drops  at  a  time,  until  the  carmine-red 
color  disappears.  While  titrating  stir  the  mixture  constantly  with 
a  glass  rod.  Note  the  number  of  cubic  centimetres  of  NaOH  that 
have  run  out.1 

To  estimate  the  quantity  of  free  HC1,  multiply  the  number  of 
cubic  centimetres  of  NaOH  used  in  the  titration  by  0.0365;  the 
result  is  the  percentage  of  free  HC1.  Normal  free  HC1  varies  from 
0.07  to  0.2  per  cent,  or  from  2  to  6  c.c.  of  decinormal  NaOH  for  10 
c.c.  of  gastric  contents. 

The  estimation  of  combined  HC1  and  of  the  acid  salts  is  seldom 
of  importance. 

Total  acidity  is  determined  by  adding  to  the  same  beaker  of 
contents  in  which  the  free  HC1  has  just  been  neutralized  two  or 
three  drops  of  a  one-per-cent  solution  (alcoholic)  of  phenolphthalein, 
and  continuing  the  titration  with  the  NaOH  solution  (and  constant 
stirring)  until  a  permanent  red  color  appears.  By  mutiplying  the 
number  of  cubic  centimetres  of  NaOH  used  from  the  beginning  of 
the  first  titration  up  to  the  point  when  the  red  color  reappears  by 
0.0365,  we  obtain  a  figure  i  presenting  the  percentage  of  total  acid- 
ity. The  normal  range  of  total  acidity  is  from  0.15  to  0.3  per  cent, 
and  we  usually  find  that  we  have  used  from  4  to  8  c.c.  of  the  NaOH 
solution  in  the  process  of  neutralizing  10  c.c.  of  gastric  contents. 

Lactic  acid  is  to  be  tested  for  only  when  SCI  is  absent.  The 
test  must  be  made  at  once,  since  lactic  acid  soon  develops  in  stom- 
ach contents  which  are  kept  in  a  warm  place.  To  perform  the  test, 
we  dilute  a  solution  of  FeCl  (strong  aqueous)  with  water  until  a 
faint  yellow  color  barely  remains.  Then  fill  the  concavities  of  two 
test  tubes  with  this  solution,  using  one  for  comparison.  If,  on 

1  An  ordinary  medicine-dropper  may  be  substituted  for  the  burette  if  we 
get  an  apothecary  to  mark  with  a  file  upon  it  the  point  to  which  a  (previously 
measured)  cubic  centimetre  of  water  rises  when  sucked  into  the  dropper. 
The  half-centimetre  point  can  be  similarly  marked.  Decinormal  NaOH  solu- 
tion is  then  sucked  into  the  dropper  and  expelled,  one-half  centimetre  at  a 
time,  into  the  beaker  containing  the  TSpfer's  reagent  and  gastric  contents. 


384  PHYSICAL  DIAGNOSIS. 

adding  a  few.  drops  of  stomach  contents  to  the  other,  a  considerable 
intensification  of  the  yellow  color  occurs,  lactic  acid  is  almost  cer- 
tainly present.  A  negative  test  rules  out  lactic  acid. 

The  sediment  need  not  be  examined.  It  is  true  that  sarcinse  and 
various  bacteria  (Boas-Oppler  bacillus  and  others)  are  often  found 
in  cases  of  gastric  stasis,  but  they  add  little  if  anything  to  the  other 
evidence  of  stasis  more  easily  obtained — i.e.,  the  symptoms  men- 
tioned on  page  386,  the  presence  of  splashing  more  than  four  hours 
after  a  meal,  the  evidence  of  dilatation  or  gastroptosis  as  given 
above,  and  the  finding  of  organic  acids. 

4.  Incidence  and  Diagnosis  of  Gastric  Diseases. 

In  the  wards  of  the  Massachusetts  General  Hospital  the  number 
of  cases  apparently  of  gastric  disease  treated  between  1870  and  1905 
was  as  follows : 

Cancer 403 

Ulcer 536 

Dilatation 170 

Dyspepsia1 1,002 


Total 2,111 

The  data  at  our  disposal  are  as  follows : 

1.  The  history. 

2.  The  local  and  external  examination  of  the  epigastric  region. 

3.  The  estimation  of  the  size  and  motor  power  of  the  stomach. 

4.  The  examination  of  the  gastric  contents. 

(a)  In  advanced  cancer  of  the  stomach  we  have  pain,  emaciation, 
anaemia,  symptoms  of  fermentation  (see  page  386),  often  dilatation 
and  motor  insufficiency  due  to  pyloric  stenosis,  absence  of  HC1  in 
the  gastric  contents  (often),  and  in  many  cases  the  presence  of 
digested  blood  ("coffee  grounds")  in  the  gastric  contents  and  occult 
blood  (guaiac)  in  the  faeces.  But  without  the  presence  of  an  epigas- 
tric tumor  all  these  facts  are  insufficient  for  diagnosis.  Even  the 

1  I.e.,  cases  of  painful  digestion  including  anomalies  of  motion,  sensation, 
secretion,  "gastritis"  and  "gastric  catarrh,"  but  without  evidence  of  ulcer, 
cancer,  or  dilatation. 


THE  STOMACH,    LIVER,    AND  PANCREAS.  385 

tumor  itself  may  deceive  us,  as  the  adhesions  around  a  gastric  ulcer 
may  present  a  similar  mass  to  the  palpating  hand. 

The  age  of  the  patient  is  of  great  importance,  especially  if  dur- 
ing the  earlier  decades  of  life  he  has  been  totally  free  from  gastric 
symptoms.  Any  type  of  dyspepsia,  any  sort  of  genuine  gastric 
trouble,1  occurring  in  a  person  over  forty  who  has  never  had  any 
such  trouble  before,  is  strongly  suggestive  of  cancer. 

(&)  Gastric  ulcer  gives  us  usually  the  symptoms  of  hyperacid- 
ity (next  paragraph),  perhaps  a  demonstrable  excess  of  HC1  in  the 
gastric  contents  and  a  more  or  less  characteristic  history ;  but  with- 
out the  occurrence  of  hemorrhage  with  the  vomiting  of  bright  blood 
and  perhaps  tarry  stools  (melsena),  diagnosis  is  never  certain. 
Since  gastric  ulcer  often  leads  to  cicatricial  stenosis  at  or  near  the 
pylorus,  its  symptoms  are  frequently  complicated  by  those  of  gas- 
tric dilatation  and  stasis. 

(c)  Hyperacidity  (or,  more  strictly,  hyperchlorhydria)  gives  us 
usually  painful  digestion,  with  a  good  appetite  and  a  clean  tongue. 
Pain  may  come  soon  after  a  meal,  and  in  such  cases  it  is  apt  to  be 
excited  especially  by  eating  meat,  but  it  is  oftener  felt  when  the 
stomach  is  quite  empty — e.g.,  in  the  night  or  before  a  meal.     It  is 
prone  to  occur  in  chlorotic  or  neurotic  persons  or  during  periods  of 
special  stress  and  worry.     It  frequently  leads  to  gastric  ulcer. 

(d)  Hypoacidity   (hypochlorhydria)    is    not    a  disease,   but  a 
symptom  occurring  temporarily  or  for  a  longer  period  in  connection 
with  various  stomach  troubles  (dilatation,  "catarrh,"  nervous  dys- 
pepsia), as  well  as  in  many  conditions  entailing  general  debility 
with  stomach  symptoms.      Hypoacidity  is  often  associated  with 
stasis  and  fermentation.     It  is  recognized,  of  course,  by  the  chem- 
ical tests  described  above. 

(e)  Gastric  dilatation,  when  considerable,  is  almost  always  sec- 
ondary to  pyloric  obstruction  (due  to  cancer,  cicatrix,  or  adhesions). 
Symptoms  suggesting  it  are  the  vomiting-at  one  time  of  a  large 
quantity — a  quart  or  more — of  stomach  contents,  often  containing 
fragments  of  food  eaten  more  than  eight  hours  previously.     Such 

1  We  must  be  careful  to  exclude  angina  pectoris  as  well  as  gall  stones  and 
their  effects. 
25 


386  PHYSICAL   DIAGNOSIS. 

attacks  of  vomiting  occur  usually  not  after  every  meal,  but  at 
longer  intervals.  .  It  is  to  be  positively  diagnosed  by  passing  a  tube 
and  distending  the  stomach  with  air  or  water. 

(/)  Gastric  stasis  occurs  with  more  or  less  constancy  in  almost 
every  disease  of  the  stomach  and  in  many  general  constitutional 
diseases  (tuberculosis,  anaemia,  general  debility).  It  constitutes 
what  is  usually  referred  to  by  patients  as  "  indigestion,"  "  dyspep- 
sia," or  "sour  stomach."  fermentation  of  stomach  contents  too 
long  retained  is  the  essential  point.  This  results  in  a  sense  of 
weight  and  pressure  in  the  epigastrium,  eructations  of  gas  and  of 
sour  or  burning  fluids,  loss  of  appetite,  nausea,  and  vomiting.  The 
tongue  is  generally  furred  and  the  bowels  are  constipated.  Head- 
ache, vertigo,  and  depression  of  spirits  often  accompany  it. 

THE  LIVER. 

The  Massachusetts  General  Hospital  records  (1870-1905)  show 
the  following  figures  bearing  on  the  incidence  of  diseases  of  the 
liver : 

Passive  congestion 1,288 

Portal  cirrhosis , 234 

Biliary  cirrhosis  (Hanot's) 0 

Cancer  of  the  liver 184 

Sarcoma  of  the  liver 2 

Abscess  of  the  liver 51 

Leukaemic  infiltration 46 

Pseudoleuksemic  infiltration 10 

Amyloid  infiltration 9 

Fatty  infiltration 6 

Hydatid  cyst 8 

Syphilis 8 

"  Simple  cyst  " 6 

Actinomycosis  3 

Acute  yellow  atrophy 2 

Tuberculosis f 1 

Total 1,858 


THE  STOMACH,    LIVER,    AND  PANCREAS.  387 

Diseases  of  the  Gall  Bladder  and  Bile  Ducts. 

Cholelithiasis    457 

A«ute  cholecystitis 110 

Catarrhal  jaundice 125 

Cholangitis 9 

Total 701 

The  evidences  of  liver  disease  may  be  either  local  or  general. 

Local  signs  include:  (a)  Pain  and  tenderness  in  the  hepatic  re- 
gion. (&)  Enlargement  of  the  organ,  symmetrical  or  irregular,  (c) 
Atrophy  of  the  organ. 

The  general  signs  which  assist  in  the  diagnosis  of  liver  disease 
are:  (a)  Portal  obstruction,  (b)  Jaundice,  including  changes  in 
the  color  of  the  skin,  mucous  membranes,  and  excretions,  (c)  Loss 
of  flesh  and  strength,  (d)  Evidences  of  infection  (fever,  leucocy- 
tosis,  chills,  sweats,  anorexia),  (e)  Cerebral  symptoms  (headache, 
vomiting,  depression,  delirium,  convulsions,  coma). 

The  various  attempts  to  test  the  liver  functions  by  chemical 
examination  of  urine  and  faeces  have  not  as  yet  been  successful; 
hence  all  diagnoses  of  liver  disease  must  be  built  up  of  the  above 

eight  groups  of  data, 
i 

(a)  Hepatic  Pain, 

This  forms  little  or  no  part  of  many  cases  of  liver  disease,  since 
it  occurs  only  when  the  capsule  is  stretched  or  its  nerves  are  involved 
in  a  perihepatitis.  Many  cases  of  hepatic  abscess,  for  example,  run 
their  course  without  pain  or  become  painful  only  when  the  pus  bur- 
rows to  the  surface  and  stretches  the  capsule.  Besides  this  capsule 
pain  in  liver  disease,  we  have  shoulder  pain  referred  to  the  region  of 
the  right  scapula,  less  often  to  other  parts  of  the  back.  Capsule  pain 
is  most  noticeable  in  cancer  of  the  liver ;  shoulder  pain  in  abscess. 

Tenderness  is  present  in  the  same  cases  which  are  painful,  i.e. , 
those  in  which  there  is  perihepatitis  or  stretching  of  the  capsule 
by  rapidly  increasing  tension  from  within.  The  latter  condition  is 
commonest  in  passive  congestion,  but  is  not  characteristic  of  any 
single  disease. 


388  PHYSICAL  DIAGNOSIS. 


(5)  Enlargement  of  the  Liver. 

Tumors  behind  the  liver,  pushing  it  forward  and  down,  are  of- 
ten overlooked,  because  they  bring  the  liver  so  prominently  into  the 
foreground  and  fasten  our  attention  on  what  is  mistaken  for  an  en- 
largement of  the  organ.  Wherever  the  cause  of  a  supposed  enlarge- 
ment of  the  liver  is  not  obvious,  retroperitoneal  sarcoma  or  some 
other  deep-seated  tumor  should  be  suspected. 

I  have  already  alluded  to  the  possibility  of  mistaking  the  en- 
larged liver  for  empyema,  and  vice  versa  (see  above,  page  354). 

We  are  sure  of  an  increase  in  the  size  of  the  liver  only  when  we 
can  feel  its  edge  below  the  ribs  and  can  determine  by  percussion 
that  its  upper  border  is  not  depressed.1  To  feel  the  edge  of  the 
liver,  hook  the  fingers  of  both  hands  around  the  margin  of  the  right 
ribs  and  ask  the  patient  to  take  a  deep  breath.  At  the  height  of 
inspiration  an  edge  may  be  felt  to  descend  against  the  fingers  and 
to  push  its  way  beneath  them.  Unless  an  edge,  either  sharp  or 
rounded,  is  felt,  one  cannot  be  sure  of  hepatic  enlargement,  for  per- 
cussion of  the  lower  edge  of  the  liver  is  notoriously  unreliable 
Dulness  below  the  costal  margin  is  frequently  found  in  cases  with- 
out hepatic  enlargement,  and  should  never  be  relied  on  unless  the 
liver  can  be  felt. 

The  long,  smooth  edge  of  the  liver  descending  one  to  two 
inches  with  full  inspiration  is  rarely  mistaken  for  anything  else, 
but  if  the  edge  is  irregular  and  the  surface  nodular  (see  below) 
it  may  be  hard  to  distinguish  liver  from  stomach  or  possibly 
kidney. 

If  ascites  is  present,  the  presence  and  dimensions  of  an  enlarged 
liver  beneath  the  fluid  can  sometimes  be  made  out  by  dipping  (see 
above,  page  371).  If  this  is  impossible,  the  ascites  may  be  tapped, 
after  which  it  is  usually  easy  to  feel  any  enlargement  that  is  pres- 
ent, as  the  belly  walls  are  very  flaccid. 

1  A  normal  liver  may  be  pushed  down  by  air,  water,  or  solid  tumors  in  the 
lung  and  pleura,  so  as  to  be  palpable  below  the  ribs;  but  the  evidence  of  a 
cause  and  the  low  position  of  the  upper  border  usually  make  diagnosis  easy. 


THE  STOMACH,    LIVER,    AND  PANCREAS.  389 

The  causes  of  hepatic  enlargement  (in  adults'),  arranged  ap- 
proximately in  the  order  of  frequency,  are : 

1.  Passive  congestion  (later  stages  of  uncompensated  heart  dis- 
ease). 

2.  Obstructive  jaundice  (from  any  cause). 

3.  Cirrhosis. 

4.  Fatty  liver,  including  "infiltration"  and  "degeneration." 

5.  Malignant  disease. 

6.  Syphilis  of  the  liver  (congenital  or  acquired). 

7.  Abscess  of  the  liver. 

8.  Leukaemia  and  pseudoleukaemia. 

9.  Cholangitis. 

10.  Amyloid. 

11.  Hydatid  cysts. 

The  largest  livers  are  found  in  malignant  disease,  biliary  cir- 
rhosis, and  abscess. 

In  passive  congestion  the  liver  is  very  tender,  and  the  presence  of 
uncompensated  heart  disease "  usually  makes  the  diagnosis  easy. 
The  surface  of  the  organ  is  smooth  and  firm. 

In  cirrhosis  a  distinction  must  be  drawn  between  (a)  latent  or 
compensated  cases,  wholly  without  symptoms,  and  (£)  uncompen- 
sated cases,  in  which  diagnosis  depends  on  the  chronic  enlargement 
without  any  considerable  increase  under  observation,  associated 
with  evidence  of  portal  or  biliary  obstruction  (or  both^)  and  without 
much  pain  or  irregularity  of  the  liver.  Eighty  per  cent  of  the  two 
hundred  and  thirty-four  cases  recorded  at  the  Massachusetts  Gen- 
eral Hospital  showed  enlargement,  and  only -twelve  per  cent  showed 
pain  (cf.  Malignant  Disease,  below). 

The  fntty  Iwer  is  soft  and  smooth  in  feel.  The  presence  of 
phthisis  or  alcoholism  makes  us  suspect  this  diagnosis,  which  de- 
pends largely  on  excluding  other  causes  of  enlargement. 

Malignant  disease  of  the  liver  (cancer  or  sarcoma)  is  usually  sec- 

1  In  infants,  rickets,  anaemia,  and  gastro-intestinal  disturbances  often  produce 
hepatic  enlargement,  though  the  splenic  enlargement  is  usually  much  greater. 
(The infant's  liver  is  normally  |  inch  below  the  ribs  in  the  nipple  line.) 

2  Either  primary  or  resulting  from  chronic  bronchitis  and  emphysema. 


390  PHYSICAL  DIAGNOSIS. 

ondary  to  new  growth  elsewhere.  The  liver  grows  rapidly  under 
observation,  is  usually  painful  (80  per  cent  of  168  Massachusetts 
Hospital  cases)  and  nodular.  Jaundice  and  irregular  fever  are 
present  in  over  one-half  of  the  cases  (54  and  62  per  cent  respec- 
tively), and  the  loss  of  flesh  and  strength  is  marked. 

Obstructive  jaundice  (due  to  stone,  stricture,  catarrh,  or  tumor 
of  the  bile  ducts,  or  to  any  other  cause)  often  produces  an  enlarged 
liver.  Diagnosis  depends  on  the  evidence  of  a  cause  for  the  ob- 
struction and  the  absence  of  hepatic  nodules,  pain,  or  a  rapid  in- 
crease in  the  size  of  the  organ. 

Syphilitic  liver  may  be  distinguishable  from  cirrhosis  or  from 
malignant  disease  only  by  the  therapeutic  test.  The  history  or 
present  evidences  of  alcoholism  or  of  syphilis  are  important  factors 
in  diagnosis,  but,  since  syphilis  may  simulate  the  nodular  liver  of 
malignant  disease  or  the  general  enlargement  and  portal  stasis  of 
cirrhosis,  it  is  essential  to  give  antisyphilitic  treatment  in  all  doubtful 
cases  of  liver  disease. 

Abscess  of  the  liver  produces  enlargement,  pain,  fever,  leucocy- 
tosis,  and  chills  in  typical  cases,  but  any  of  these  symptoms  may 
be  absent  and  diagnosis  is  often  difficult.  The  presence  of  a  possi- 
ble cause  (amosbic  dysentery,  appendicitis)  is  important  evidence. 
The  enlargement  is  more  apt  to  be  upward  and  to  the  right  than  in 
other  liver  diseases,  since  the  pus  usually  starts  in  the  right  lobe 
and  burrows  upward.  Hence  many  cases  are  mistaken  for  empyema 
(see  above,  page  354).  Should  fluctuation  appear  externally  the 
diagnosis  is  usually  obvious,  but  in  many  cases  this  does  not  oc- 
cur. • 

Soft  new  growths  and  syphilis  may  be  almost  indistinguishable 
from  abscess  by  local  signs,  but  jaundice  is  much  commoner  in  ma- 
lignant disease  and  the  liver  of  syphilis  is  often  irregular.  The 
history  is  of  value. 

Suppurative  cholanaitis  or  pylephlebitis  gives  us  practically  the 
same  symptoms  as  abscess,  but  the  spleen  is  enlarged  in  about  one- 
third  of  the  cases. 

Amyloid  liver  is  recognized  by  the  presence  of  an  appropriate 
cause  (chronic  suppuration  or  syphilis)  and  the  evidence  of  amyloid 


THE  STOMACH,    LIVER,    AND  PANCREAS.  391 

in  other  organs  (enlarged  spleen,  albuminuria,  diarrhoea).  The 
liver  is  smooth,  not  irregular  as  in  hepatic  syphilis. 

The  leukcp-mic  liver  is  recognized  by  blood  examination ;  the 
pseudo-leuksemic  liver  by  the  normal  blood  and  the  histological 
examination  of  the  glandular  enlargements  vhich  always  accom- 
pany it. 

Hydatid  cyst  is  rarely  to  be  diagnosed  by  physical  signs.  The 
history  of  a  residence  in  Australia,  Iceland,  certain  parts  of  Ger- 
many, or  of  the  British  Isles  is  important  evidence,  since  the 
disease  has  never  been  known  to  originate  in  North  America.  Physi- 
cal examination  may  enable  us  to  make  out  that  the  hepatic  enlarge- 
ment is  due  to  a  cystic  tumor,  tense  and  elastic,  with  notable 
absence  of  constitutional  disturbances  (Rolleston). 

(c\  Atrophy  of  the  Liver. 

Diminution  in  the  size  of  the  liver  can  hardly  ever  be  demon- 
strated satisfactorily  during  life,  since  we  must  rely  upon  percus- 
sion for  our  evidence,  and  percussion  of  the  upper  and  of  the  lower 
border  of  the  liver  may  be  rendered  difficult  by  distention  of  the 
lung  (emphysema)  or  of  the  colon.  Atrophy  occurs  in  a  small  pro- 
portion of  the  cases  of  hepatic  cirrhosis  and  in  acute  yellow  atrophy, 
but  is  rarely  recognized  in  either  condition.  The  rapidly  fatal 
course  of  the  latter  disease  with  jaundice  and  a  "typhoidal  state" 
contrasts  with  the  prolonged  portal  stasis  characteristic  of  cirrhosis. 

(rf)   Portal  Obstruction. 

A  characteristic  group  of  signs  manifest  the  presence  of  an  ob- 
stacle to  the  flow  of  blood  through  the  portal  system.  This  group 
includes : 

1.  Haematemesis  and  dyspepsia. 

2.  Ascites  '  (see  page  374). 

3.  Splenic  enlargement.1 

1  Ascites  and  splenic  enlargement  are  not  purely  mechanical  phenomena 
Toxaemia  and  sometimes  chronic  peritonitis  or  cardiac  failure  contribute. 


392  PHYSICAL  DIAGNOSIS. 

4.  Collateral  dilatation  of  veins  about  the  navel  and  elsewhere. 

Hcematemesis  is  usually  due  to  rupture  of  dilated  cesophageal 
veins,  occasionally  to  gastritis. 

Splenic  enlargement  is  more  marked  in  the  rare  cases  associated 
with  chronic  jaundice  (biliary  cirrhosis}  and  without  ascites. 

The  cause  of  portal  obstruction  is :  1.  Cirrhosis,  in  ninety-five 
per  cent  of  the  cases.  The  remaining  five  per  cent  is  made  up 
of :  2.  Obliterations  of  the  portal  vein,  usually  by  thrombosis  or 
tumors. 

(e)  Jaundice. 

The  yellow  staining  of  sclera,  skin,  and  mucous  membranes, 
with  or  without  changes  in  the  color  of  the  urine  and  faeces,  is 
known  as  jaundice.  I  have  classed  it  as  a  general  rather  than  a 
local  sign  of  liver  disease,  because  it  may  occur  from  toxaemia  and 
independent  of  any  lesion  of  the  liver;  for  instance,  in  septicaemia, 
malaria,  yellow  fever,  and  pernicious  anaemia.  It  is  true,  never- 
theless, that  all  jaundice  is  due  ultimately  to  obstruction  in  the 
path  of  the  bile  stream.  In  the  toxaemic  cases  the  obstruction  is 
due  to  inflammation  of  some  of  the  small  ducts  within  the  liver.  In 
the  cases  due  to  stone  or  cancer  the  obstruction  is  in  the  larger  bile 
ducts,  usually  the  common  duct. 

Causes  of  Jaundice. — The  four  types  most  often  seen  are: 

1.  Jaundice  of  the  new-born  (occurs  in  from  thirty  to  eighty  per 
cent  of  all  children). 

2.  Catarrh  of  the  bile  ducts  ("catarrhal  jaundice  "). 

3.  Gall  stones,  especially  in  the  common  duct. 

4.  Cancer  (pancreas,  glands,  liver,  or  bile  ducts). 
Less  common  are  the  cases  due  to : 

5.  Cirrhosis  of  the  liver. 

6.  Syphilis  of  the  liver. 

7.  Infectious  disease  or  toxaemia. 
Rare  causes  are : 

8    Acute  yellow  atrophy,  with  or  without  phosphorus  poisoning. 

9.  Weil's  disease  and  other  types  of  infectious  jaundice. 

10.  Congenital  obliteration  of  the  bile  ducts. 


THE  STOMACH,    LIVER,    AND  PANCREAS.  393 

The  results  of  jaundice  upon  the  body  are  chiefly  the  following : 
(a)  Slow  pulse  (often  below  60).  (&)  Itching  of  the  skin,  (c) 
Mental  depression,  (d)  Hemorrhagic  tendency  (which  renders 
operation  dangerous). 

In  mild  cases  there  is  no  bile  in  the  urine;  in  severe  cases  it  is 
almost  always  present.  The  stools  are  gray  or  clay-colored  when 
the  obstruction  is  in  the  larger  bile  ducts  outside  the  liver,  but  in 
the  toxaemic  forms  of  jaundice  abundance  of  bile  passes  into  the 
intestine  and  the  stools  are  of  normal  color. 

Diagnosis  of  the  cause  of  jaundice  depends  on  the  following  con- 
siderations : 

1.  If  it  occurs   during  the  first  four  days  of  life  without  any 
other  symptom  and  passes  off  within  a  few  weeks,  we  call  it  simple 
jaiindice  of  the  neiv-born. 

2.  If  the  attack  is  preceded  by  gastro-intestinal  disturbances, 
usually  in  a  young  person,  if  pain  and  hepatic  enlargement  are 
slight  or  absent,  and  if  the  jaundice  passes  off  within  six  weeks,  we 
term  it  "  catarrhal  jaundice"  (though  the  pathology  of  this  and  of 
the  preceding  condition  is  unknown). 

3.  If  there  have  been  attacks  of  biliary  colic  (see  below,  page 
393),  intermittent  fever  with  intervals  of  good  health,  and  no  con- 
siderable or  progressive  enlargement  of  the  liver  or  gall  bladder, 
stone  in  the  common  duct  is  probably  the  diagnosis. 

4.  Cancer  of  the  pancreas,  duodenal  papilla,  bile  ducts,  or  of 
the  glands  at  the  hilus  of  the  liver,  produces  enlargement  of  the 
gall  bladder,  pain,  and  a  jaundice  of  the  intensest  type  known. 
Loss  of  flesh  and  strength  is  rapid.     Cancer  of  the  liver  itself  gives 
a  rapidly  enlarging,   nodular  liver  with  steady  pain,  and,  in  fifty 
per  cent  of  cases,  jaundice. 

5.  In  ordinary  portal  cirrhosis  the  jaundice  is  less  intense  and 
permanent,  portal  stasis  is  usually  evident,  and  there  is  generally 
a  moderate  enlargement  of  the  liver. 

6.  Enlargement  of  the  liver  with  jaundice  lasting  for  years  in 
young  people  is  called  biliary  cirrhosis. 

7.  Hepatic  syphilis  produces  jaundice  in  a  small  percentage  of 
cases,  and  under  these  conditions  is  so  apt  to  be  mistaken  for  cancer 


394  PHYSICAL  DIAGNOSIS. 

that  I  think  all  cases  supposed  to  be  cancer  in  or  near  the  liver 
should  be  given  a  course  of  antisyphilitic  treatment.  Other  lesions 
or  symptoms  of  syphilis  will  naturally  influence  us. 

8.  The  jaundice  secondary  to  septicaemia,  yellow  fever,  malaria, 
and  pernicious  anaemia  is  usually  slight  and  rarely  shows  in  the 
urine  or  bleaches  the  stools.     The  evidence  of  the  anaemia  or  of  an 
infection  makes  evident  the  nature  of  the  jaundice. 

9.  Acute  yellow  atrophy  cannot  be  determined  without  autopsy. 
Its  chief  symptoms  are  given  in  its  name. 

10.  Weil's  disease  is  the  term  applied  to  some  or  all  of  the 
groups  of  infections  of  unknown  origin  which  are  accompanied  by 
jaundice.     From  catarrhal  jaundice  it  is  to  be  distinguished  during 
life  only  by  convincing  evidence  of  general  infection. 

Congenital  obliteration  of  the  biliary  ducts  is  suggested  by  the 
occurrence  of  congenital,  intense,  and  permanent  jaundice  with 
hemorrhage  and  enlargement  of  the  liver  and  spleen. 

(/)   Loss  of  flesh  and  Strength, 

in  cases  presenting  other  signs  of  liver  disease  is  commonest  in 
uncompensated  cirrhosis  and  in  malignant  disease,  but  may  occur  in 
gall-stone  disease,  syphilis,  or  abscess.  I  have  known  a  physician 
greatly  alarmed  at  his  own  rapid  emaciation,  though  his  symptoms 
(jaundice  and  colic)  pointed  to  stone  in  the  common  duct  and  opera- 
tion proved  this  diagnosis  correct. 

(g)   The  Infection  Group  of  Symptoms. 

These  symptoms — viz.,  fever,  chills,  sweats,  leucocytosis,  dis- 
turbances of  digestion  and  sleep — are  oftenest  seen  in  :  1.  Cholan- 
gitis.  2.  Hepatic  abscess.'  3.  "Ball- valve"  or  " floating "  stone 
in  the  common  duct.  In  the  last  disease  jaundice  is  usually  pres- 
ent ;  in  the  others  usually  absent.  In  cancer  of  the  liver  fever  and 
leucocytosis  are  often  present,  but  the  other  signs  of  infection  are 
rarely  seen. 

1  With  or  without  pylephlebitis. 


THE  STOMACH,    LIVER,   AND  PANCREAS.  395 

(Ji)   The  Cerebral  Symptoms  of  Liver  Disease. 

These  vary  from  simple  depression  and  apathy  to  delirium,  con- 
vulsions, and  coma.  Severe  symptoms  are  oftenest  seen  at  the  end 
of  uncompensated  cirrhotic  cases ;  eighty-two  per  cent  of  our  fatal 
cases  showed  during  the  last  days  of  life  symptoms  indistinguishable 
from,  those  of  uraemia. 

THE  GALL  BLADDER  AND  BILE  DUCTS. 

(a)  Biliary  colic,  and  (b)  enlarged  gall  bladder,  with  or  without 
tenderness  and  pain,  are  the  data  on  which  (with  the  evidence  of 
local  or  general  infection,  cachexia,  intestinal  obstruction,  and  jaun- 
dice) our  knowledge  of  gall-bladder  disease  is  built  up. 

Differential'  Diagnosis  of  Biliary  Colic. 

Biliary  colic,  due  to  impaction  of  a  gall  stone  in  the  cystic  or 
common  duct,  is  a  sudden,  agonizing  pain  in  the  gastric  or  hepatic 
region,  radiating  thence  in  all  directions,  with  fever,  chills,  and 
vomiting.  In  most  cases  the  attack  lasts  from  three  to  twelve  hours 
(Rolleston)  unless  reliered  by  morphine.  The  pains  may  be  of  any 
degree  of  severity,  and  are  often  accompanied  by  tenderness  over 
the  hepatic  region.  The  liver  or  gall  bladder  is  seldom  palpable. 
Jaundice  precedes  or  follows  the  attack  in  about  one-half  of  the 
cases. 

Renal  colic  differs  in  that  it  usually  starts  over  the  kidney  (in 
the  back)  and  radiates  down  the  ureter,  while  the  urine  is  apt  to  be 
bloody  but  free  from  bile. 

Floating  kidney  may  produce  pains  which  cannot  in  themselves 
be  distinguished  from  biliary  colic.  The  palpation  of  the  floating 
kidney  may  be  all  that  makes  us  suspect  that  organ  to  be  the  cause 
of  suffering. 

Peptic  ulcer  (gastric  or  duodenal)  produces  sharp,  paroxysmal 
pain,  but  this  usually  follows  a  meal,  can  be  relieved  by  alkalies, 
and  produces  no  fever,  chill,  or  sweat.  Hyperchlorhydria  may 


396  PHYSICAL  DIAGNOSIS. 

^produce  similar  pain  at  night  (the  commonest  time  for  biliary  colic), 
but  is  relieved  by  food  or  alkali. 

Lead  colic  is  almost  always  associated  with  lead  dots  in  the 
gums  and  stippling  of  the  red  corpuscles  (see  pages  24  and  472). 
The  history  of  work  as  a  painter  or  plumber  and  the  absence  of  ten- 
derness assist  the  diagnosis. 

Enlarged  Gall  Bladder. 

An  enlarged  gall  bladder  cannot  be  felt  unless  it  is  stretched 
tight  by  its  contents;  a  very  tense  gall  bladder  may  be  palpable 
without  much  enlargement.  Probably  most  enlarged  gall  bladders 
are  not  tense,  and  so  cannot  be  made  out  without  operation.  When 
palpable  the  organ  presents  as  a  smooth,  rounded,  pear-shaped  tu- 
mor at  the  margin  of  the  ribs  in  the  nipple  line. 

The  causes  of  enlargement  are : 

(a)  Stone  in  the  cystic  duct,  at  the  neck  of  the  gall  bladder. 

(6)  Cancer  of  the  pancreas  or  other  tumor  obstructing  the  com- 
mon duct  from  without. l 

(c)    Cholecystitis. 

In  the  first  of  these  jaundice  is  rarely  present  (ten  to  fifteen  per 
cent — Riedel 2),  and  colic  with  or  without  palpable  tumor  is  our 
guide  to  diagnosis. 

In  cancerous  obstruction  there  is  intense  and  permanent  jaun- 
dice. 

In  cholecystitis  there  is  usually  no  jaundice,  but  all  the  signs  of 
local  and  general  infection — pain,  tenderness,  leucocytosis,  and  fever 
— are  present.  In  acute  cases  the  symptoms,  however,  may  be 
indistinguishable  from  those  of  appendicitis,  since  the  pain  may 
be  referred  to  the  navel  or  even  to  the  appendix  region.  Many 
mistakes  of  diagnosis  between  appendicitis  and  acute  cholecystitis 
occur,  and  must  occur  until  our  present  diagnostic  resources  are 
increased. 

'Courvoisier  haa  shown  that  if  the  common  duct  is  obstructed  by  a  gal' 
stone  the  gall  bladder  is  very  rarely  enlarged. 
'Riedel:  Berlin,  klin.  Woch.,  1901,  No.  8. 


THE  STOMACH,    LIVER,    AND  PANCREAS.  397 

Results  of  Cholecystitis. 

(a)  Adhesions  about  the  gall  bladder  may  involve  the  duodenum 
or  pylorus,  and  produce  kinking  and  consequent  dilatation  of  the 
stomach  and  chronic  dyspepsia. 

(b)  Intestinal  obstruction  (see  below,  page  403)  is  occasionally 
produced  by  the  ulceration  of  a  large  gall  stone  from  the  gall  blad- 
der into  the  intestine,  usually  the  small  intestine  or  duodenum. 

THE  PANCREAS. 

Diseases  of  the  pancreas  can  very  rarely  be  diagnosed  by  our 
present  methods.  If  greatly  enlarged  (tumor,  cyst,  hemorrhage) 
it  may  become  palpable  as  a  deep  epigastric  tumor,  but  we  are 
rarely  able  to  differentiate  such  tumors  from  those  of  the  retro- 
peritoneal  structures. 

Indirect  and  uncertain  information  is  afforded  by  the  presence 
in  the  urine  of  sugar  or  fat-splitting  ferments  1  and  in  the  stools  by 
the  appearance  of  an  abnormal  amount  of  muscle  fibre  or  of  fat  not 
otherwise  to  be  accounted  for  (i.e.,  in  the  absence  of  jaundice,  diar- 
rhoea, tuberculous  peritonitis,  or  large  meals  of  fat). 

Cancer  of  the  pancreas  may  sometimes  be  suspected  on  account 
of  its  pressure  effects.  Intense  and  permanent  jaundice  with  en- 
larged (perhaps  palpable)  gall  bladder  and  liver  may  be  due  to  the 
pressure  of  cancer  in  the  head  of  the  pancreas  upon  the  common 
bile  duct.  Ascites  and  swelled  legs  may  be  produced  by  compres- 
sion of  the  inferior  vena  cava.  But  the  diagnosis  can  rarely  be  more 
than  a  suspicion,  for  cancer  of  the  duodenal  papilla  or  retroperi- 
toneal  sarcoma  may  produce  similar  pressure  effects.  Should  these 
pressure  effects  coincide  with  a  glycosuria  and  the  presence  of  a  deep- 

1  The  suspected  urine  is  neutralized  with  potassium  hydroxide  and  one 
portion  of  it  boiled  to  destroy  any  ferment  that  may  be  present.  To  this  and 
to  the  unboiled  portion  ethyl  butyrate  is  added.  In  twenty -four  hours  an  acid 
reaction  may  appear  in  the  unboiled  specimen  if  it  contains  a  ferment,  while, 
the  other  specimen  shows  no  considerable  change  in  reaction. 


398  PHYSICAL  DIAGNOSIS. 

seated,  almost  immovable  tumor,  the  suggestion  of  pancreatic  disease 
becomes  more  plausible. 

Acute  pancreatic  disease,  hemorrhagic  or  suppurative,  is  not  rec- 
ognizable until  it  is  seen  at  an  operation  undertaken  for  the  relief 
of  some  grave,  acute  lesion  of  the  upper  abdomen.  Perforated  gas- 
tric ulcer  and  intestinal  obstruction  may  give  identical  symptoms, 
viz.,  sudden,  intense,  epigastric  pain  and  tenderness,  with  vomiting 
and  collapse.  One  or  two  days  later  a  tender  epigastric  tumor  may 
appear,  but  this  presents  no  characteristic  peculiarities. 

Pancreatic  cyst  presents  a  very  slow-growing,  possibly  elastic, 
deep-seated  epigastric  tumor,  which  usually  produces  little  in  the 
way  of  pressure  effects,  and  may  be  associated  with  glycosuria  and 
fatty  stools. 

Bronzed  Diabetes. — The  association  of  diabetes  with  bronzing  of 
the  skin  and  enlargement  of  the  liver  is  strongly  suggestive  of 
chronic  fibrous  pancreatitis. 

In  any  doubtful  case  the  possibility  of  pancreatic  disease  is 
increased :  (a)  If  improvement  follows  the  administration  of  pan- 
creatic preparation ;  (6)  if  glycosuria  follows  the  administration  of 
100  gm.  of  glucose  (alimentary  glycosuria). 

Incidence  of  Pancreatic  Disease. 

The  following  table  is  from  the  Massachusetts  General  Hospital 
records  (1870-1905) : 

Cases. 

Cancer  of  the  pancreas 35 

Acute  pancreatitis 13 

Chronic  pancreatitis  ....   10 

Cyst  of  the  pancreas  3 

Total..  .  61 


CHAPTER   XX. 

THE   INTESTINE,    SPLEEN,   KIDNEY. 
THE  INTESTINES. 

Incidence  of  Intestinal  Disease  (excluding  diarrhoea  and  constipa- 
tion) at  the  Massachusetts  General  Hospital,  1870-1906. 

1.  Appendicitis 3,314 

2.  Acute  obstruction 142 

3.  Cancer  (above  the  rectum) •  155 

4.  Dilated  colon 6 

5.  Tuberculosis  '.  2 

6.  Faecal  impaction  (above  the  rectum) 2 

Total 3,621 

Data  for  Diagnosis.  . 

THE  data  on  which  are  based  all  our  conclusions  regarding  intes- 
tinal disease  are  obtained  from  the  following  sources : 

1.  Pain  (colicky  or  steady)  and  tenderness,  tenesimts. 

2.  Gaseous  distention  and  the  noises  and  sensations  produced  by 
gas. 

3.  Diarrhoea  or  constipation. 

4.  Muscular  rigidity  of  the  belly  wall  protecting  an  intestinal 
lesion. 

5.  Tumor,  palpable   or  visible,  and  believed  to  be  connected 
with  the  intestines  (together  with  the  effect  of  catharsis  on  such 
tumor). 

6.  Visible  or  palpable  peristalsis  (see  page  366). 

7.  Digital  or  visual  examination  of  the  rectum  (see  page  443). 

8.  Examination  of  the  intestinal  contents,  faecal  and  other  (see 
page  404). 

9.  Inflation  of  the  colon  through  the  rectum  (see  page  372). 

10.  Indicanuria — rarely  of  value. 


400  PHYSICAL  DIAGNOSIS. 

11.  Constitutional  manifestations,  such  as  fevers,  vomiting, 
leucocytosis,  emaciation. 

Some  of  these  data  need  further  comment. 

Intestinal  Pain.  — Many  pains  associated  with  intestinal  disease 
(appendicitis,  cancer)  are  due  in  fact  to  irritation  of  the  peritoneum. 

Which  of  the  numerous  pains  referred  to  the  belly  should  be 
interpreted  as  intestinal  in  origin?  Those  especially  which  (a) 
shift  rapidly  from  place  to  place;  (i)  accompany  the  noises  and 
sensations  of  the  passage  of  gas  and  faeces  through  the  intestine ; 
(c)  accompany  diarrhoea  or  constipation. 

Tenderness  is  usually  a  symptom  of  peritoneal  rather  than  intes- 
tinal irritation.  With  true  intestinal  pain  (colic)  there  is  often 
relief  by  pressure — the  precise  opposite  of  tenderness.  Yet  so 
close  is  the  association  of  intestine  and  peritoneum  that  in  appen- 
dicitis, intestinal  ulceration,  tumors,  and  even  in  simple  gaseous 
distention  of  the  gut,  there  is  often  local  or  general  tenderness. 
When  extreme  and  associated  with  constitutional  manifestations 
— fever,  leucocytosis,  collapse — it  always  suggests  peritonitis. 
When  there  are.no  constitutional  manifestions,  a  purely  local  pain 
or  tenderness  has  little  diagnostic  value. 

Tenesmus. — The  desire  to  pass  another  stool  as  soon  as  one  has 
been  evacuated,  together  with  local  burning  and  straining,  means 
always  rectal  irritation  (inflammation,  ulcer).  It  is  one  of  the  most 
definite  and  reliable  symptoms  known. 

Gaseous  distention  of  the  intestine  is  proved  by  an  increase  of  the 
normaf  tympanitic  note  over  part  or  all  of  the  belly,  together  with 
a.  prominence  of  the  overlying  belly  wall.  It  is  chiefly  and  most 
frequently  the  colon  that  produces  distention. 

The  significance  of  distention  is  vague  and  depends  largely  on 
the  associated  data.  In  acute  g  astro-intestinal  "catarrh"  the 
diarrho3a  and  absence  of  severe  constitutional  manifestations  make 
us  put  little  stress  on  the  associated  distention.  In  typhoid  fever 
distention  results  from  atony  of  the  intestinal  walls  and  is  "  to  some 
extent  a  measure  of  the  intensity  of  the  local  lesions  "  (Osier).  In 
intestinal  obstruction  distention  may  be  extreme  if  the  stoppage  is 
low  down  (in  the  colon),  less  marked  if  the  lesion  is  high  up.  In 
starvation,  children  often  get  very  large  bellies,  owing  to  muscular 


THE  INTESTINE,   SPLEEN,    KIDNEY.  401 

atony  of  the  gut  and  the  resulting  gaseous  accumulation.  But  in 
no  case  is  the  distention  of  itself  of  much  diagnostic  value.  The 
associated  symptoms  give  it  significance. 

Diarrhoea,  the  passage  of  more  and  looser  stools  than  is  normal 
for  the  individual,  is,  like  distention,  a  result  of  many  causes  both 
within  and  outside  the  intestine. 

The  most  important  are : 

((a)  Indigestion  (acute  and  chronic). 
1    TntMHml  disease  J  <6>  Ulceration  (some  cases  only). 

lse>  j  (c)  Infectious  diseases  (cholera,  dysentery,  typhoid* 
[(rf)  Intestinal  parasites. 

{(a)  Nervous  causes  (emotion,  Basedow's  disease, 
etc  ) 
(6)  General  infections  (sepsis). 
(c)  Cachectic  states  (anemias,  nephritis,  etc.). 

By  a  search  for  these  causes,  as  well  as  by  the  use  of  the  data 
obtained  by  examination  of  the  stools,  we  arrive  at  an  understand- 
ing of  the  diagnostic  significance  of  diarrhoea. 

Aside  from  diarrhoea,  constipation,  and  dysentery,  which  produce 
no  physical  signs  beyond  those  described — distention,  borborygmi, 
pain,  tenderness,  tenesmus,  and  constitutional  manifestations — 
there  are  but  three  important  diseases  of  the  intestines : 

I.  Appendicitis. 

II.  Intestinal  obstruction. 

III.  Cancer  of  the  bowel. 

1.  Appendicitis. 

1.  The  local  signs  are  pain,  tenderness,  muscular  spasm,  and 
tumor. 

2.  The  general  or  constitutional  signs    are  fever,  chill,   rapid 
pulse,  vomiting,  constipation,  frequency  or  cessation  of  micturition, 
and  leucocytosis. 

(a)  The  pain  may  be  at  first  general,  later  localizing  itself  in  the 
right  iliac  fossa,  less  often  near  the  navel,  the  gall  bladder,  or  in 
any  other  part  of  the  belly. 

(ft)  The  tenderness  is  more  important  in  diagnosis;  indeed,  with- 
out tenderness  diagnosis  is  rarely  possible.  It  is  usually  greatest 
26 


402  PHYSICAL  DIAGNOSIS. 

near  a  point  half-way  from  the  anterior  iliac  spine  to  the  navel. 
Occasionally  a  tender  point  in  the  pelvis  may  be  reached  by  rectal 
examination,  but  this  is  not  a  reliable  sign. 

(c)  Muscular  spasm  over  the  appendix  region  is  present  in  most 
cases,  and,  while  it  renders  accurate  palpation  impossible,  it  is  in 
itself  so  characteristic  of  the  disease  that  we  do  not  regret  it. 

~PSOOS  spasm  occurs  in  a  minority  of  cases.  The  patient  leans 
his  body  forward  and  toward  the  right  in  walking,  or,  if  recum- 
bent, draws  up  the  right  thigh  to  relax  the  spasm. 

(cT)  Tumor — about  the  size  and  shape  of  a  lemon,  ill-defined  and 
tender — is  felt  in  the  right  iliac  fossa  in  many  cases.  It  may  be 
considerably  larger  and  better  defined  if  abscess'  has  existed  for  sev- 
eral days,  or  it  may  be  smaller  and  more  sausage-shaped. 

(e)  The  constitutional  signs  may  or  may  not  be  marked,  accord- 
ing to  the  duration  of  the  process,  its  virulence,  and  the  degree  of 
infection  of  the  peritoneal  cavity.  The  fever  is  usually  moderate, 
under  102.2°  F.,  with  corresponding  elevation  of  the  pulse.  Vom- 
iting comes  at  the  outset  if  at  all,  and  is  usually  over  by  the  second 
day.  A  leucocyte  count  which  rises  or  remains  elevated  (above 
16,000)  accompanies  the  active  and  advancing  stages  of  the  disease. 
In  cases  that  are  very  mild  or  tightly  walled  in  by  adhesions,  and 
in  cases  with  virulent  general  peritonitis,  the  leucocytes  may  be 
normal  or  subnormal. 

Diagnosis  can  hope  only  to  establish  the  existence  of  a  local 
inflammatory  process  in  the  abdomen ;  acute  cholecystitis  and  acute 
pus  tube  may  present  signs  indistinguishable  from  those  of  appen- 
dicitis, though  the  site  of  tenderness  often  sets  us  right.  Non- 
inflammatory processes,  such  as  biliary  and  renal  colic,  floating 
kidney,  and  acute  gastro-intestinal  upsets,  can  usually  be  excluded, 
since  they  do  not  show  so  much  local  tenderness,  fever,  and  leuco- 
cytosis. 

In  those  who  are  familiar  with  the  symptoms  of  appendicitis,  a 
vivid  imagination  may  conjure  up  a  set  of  sensations  that  are  diffi- 
cult for  the  physician  to  distinguish  from  those  of  the  actual  dis- 
ease. Even  tenderness  may  be  simulated,  but,  by  distracting  the 
patient's  attention  while  we  palpate,  we  may  be  able  to  press  hard 
over  the  appendix  without  eliciting  complaint.  The  absence  of  leu- 


THE  INTESTINE,   SPLEEN,    KIDNEY.  403 

cocytosis,  the  age  and  sex  of  the  patient,  also  help  us  to  exclude 
appendicitis. 

//.   Intestinal  Obstruction. 

(a)  Acute  Obstruction. — A  person  may  have  had  no  faecal  discharge 
for  a  week  or  even  considerably  longer  and  yet  present  all  the  evi- 
dences of  good  health.  It  is  only  when  vomiting,  severe  paroxysms 
of  pain,  and  distention  of  the  belly  ensue  that  we  suspect  obstruc- 
tion. In  the  acute  cases  tumor  is  noted  in  only  about  fifteen  per  cent. 
In  the  chronic  cases,  usually  due  to  stricture  or  cancer,  a  fsecal 
tumor  can  often  be  felt  and  diarrhoea  may  alternate  with  constipation. 

By  physical  signs  alone  I  do  not  believe  that  general  peritonitis 
and  acute  intestinal  obstruction  can  always  be  distinguished.  Fever 
is  not  distinctive  of  general  peritonitis,  for  it  occurred  in  eighty-four 
out  of  one  hundred  and  twenty-two  cases  of  acute  obstruction  in  the 
Massachusetts  Hospital  records,  and  in  forty-three  of  these  cases 
free  fluid  in  the  peritoneal  cavity  was  demonstrated  as  well.  Ster- 
coraceous  vomiting  may  occur  in  general  peritonitis ;  it  was  absent 
in  three-fourths  of  the  Massachusetts  Hospital  cases  of  obstruction. 
Weak,  rapid  pulse,  cold  extremities,  and  a  drawn,  anxious  face  are 
common  to  both  diseases.  Tenderness  is  more  general  and  more 
marked  in  general  peritonitis  than  in  simple  obstruction,  yet  some 
tenderness  was  complained  of  in  fifty -six  out  of  the  one  hundred  and 
twenty-two  cases  of  obstruction  just  cited. 

On  the  whole,  the  differential  diagnosis  of  these  two  diseases 
seems  to  depend  far  more  on  the  history  and  the  etiology  than  on 
physical  signs. 

(6)  Chronic  Obstruction. — -Here  the  diagnosis  is  simpler.  There 
is  usually  a  history  of  increasing  constipation  sometimes  interrupted 
by  occasional  attacks  of  diarrhoea.1  Tumor  is  palpable  in  fifty-eight 
per  cent  of  cases.  Visible  peristalsis  was  recorded  in  seventeen  per 
cent  of  the  Massachusetts  Hospital  cases.  Distention  is  gradual  and 
late.  Cachexia  is  frequently  present.  Cancer  of  the  colon,  usually 
at  the  sigmoid  or  caecum,  is  the  commonest  cause.  Stricture,  ex- 
cept cancerous  stricture,  is  rare. 

1  The  latter  combination  occurred  in  six  per  cent  of  the  Massachusetts  Hos- 
pital cases. 


404  PHYSICAL  DIAGNOSIS. 

(c)  Acute  Obstruction  by  a  Chronic  Lesion. — Cancer  of  the  sigmoid 
often  exists  for  months  almost  latent,  or  produces  only  moderate 
constipation,  so  that  the  patient  considers  himself  well.  Such  can- 
cers present  an  annular  growth,  hardly  bigger  than  a  signet-ring, 
practically  an  annular  stricture. 

This  stricture  may  be  suddenly  "  shut  down "  during  an  acute 
gastro-intestinal  attack,  and  we  are  then  confronted  with  all  the 
signs  of  acute  obstruction.  Only  the  seat  of  the  lesion,  the  age  of 
the  patient,  and  possibly  the  appearance  of  peristaltic  waves  can 
lead  us  aright  in  our  diagnosis  of  the  cause  of  obstruction. 

III.    Cancer  of  the  Bowel. 

The  signs  are  usually  those  of  chronic  intestinal  obstruction  (see 
last  section)  with  a  well-defined  tumor.  Occasionally  the  tumor 
may  not  produce  much  obstruction,  and  we  have  simply  pain  and  a 
tumor  which  we  find  by  examination  is  not  attached  to  the  liver, 
spleen,  kidney,  or  stomach,  and  usually  about  the  size  of  a  hen's 
egg.  If  faeces  have  accumulated  behind  such  a  tumor,  we  may  feel 
larger  masses.  In  my  experience  palpable  tumors  due  to  faecal  im- 
paction  alone,  without  organic  stricture  or  cancer,  are  very  rare,  ex- 
cept in  the  rectum  or  lower  sigmoid ;  if  found  above  this  region  they 
are  almost  invariably  dependent  on  stricture  or  cancer  of  the  bowel. 

Examination  of  Intestinal  Contents. 

1.  Weight. — With  the  average  diet  of  the  adult  "  Anglo-Saxon," 
the  weight  of  the  daily  stool  is  from  100  to  250  gm.  (about  25  to 
70  gm.  dry),  but  Chittenden  has  shown  that  with  a  low  proteid  diet 
of  2,000-2,750  calories  value,  the  weight  of  the  stool  may  be  less 
than  half  this  amount.1 

2.  Color. — (a)    White  or  light  yellow — milk  diet,   bread  and 
milk  diet. 

(£)  Black — blood,  bismuth  or  iron  (medicinal),  blackberries, 
huckleberries,  red  wine. 

1  "Physiological  Economy  in  Nutrition,"  1904,  p.  42. 


THE  INTESTINE,  SPLEEN,  KIDNEY.  405 

(c)  Green;  some  normal  infants'  stools  after  standing ;  fermented 
infant's  stool  if  green  when  passed;   green  vegetables,  calomel. 

(d)  Gray — absence  of  bile  (jaundice),  sometimes  after  cocoa  or 
chocolate. 

(e)  Bloody  red — if  in  small  amount  and  fresh,  usually  due  to 
hemorrhoids ;  in  large  amounts  it  may  also  be  due  to  hemorrhoids 
or  to  any  of  the  causes  of  intestinal   ulceration  (typhoid,  cancer, 
dysentery,  etc.). 

3.  Odor. — In  adults  of  no  great  significance.     In  infants  foul 
stools  suggest  albuminoid  decomposition,  and  strongly  sour  stools 
suggest  acid  fermentation. 

4.  Abnormal  Ingredients. — (a)    Undigested  food  in  small  quan- 
tities is  present  in  normal  stools,  but  when  digestion  is  faulty  larger 
quantities  easily  recognized  by  the  naked  eye  may  occur.     Pieces 
of  meat,  flakes  of  casein  (especially  in  typhoid  patients  overfed 
with  milk),  fragments  of  starchy  food,  and  lumps  of  fat  (steator- 
rhcea)  may  be  seen. 

The  natural  inference  from  the  presence  of  these  substances  is 
that  the  gastro-intestinal  tract  is  not  at  present  dealing  with  them 
satisfactorily.  Fatty  stools  are- present  in  jaundice,  tuberculosis, 
or  amyloid  of  the  intestine,  and  even  in  simple  catarrh.  Though 
often  associated  with  pancreatic  disease,  fatty  stools  are  by  no  means 
characteristic  of  it. 

(£)  Mucus. — Small  shreds  of  mucus  adherent  to  faeces  are  of 
no  importance  and  cause  much  unnecessary  worry  among  anxious 
mothers.  Larger  amounts,  if  intimately  mixed  with  the  stool,  point 
to  catarrh  of  the  small  intestine;  if  mucus  thickly  coats  or  makes 
up  the  bulk  of  the  stool,  the  trouble  is  in  the  colon.  The  latter  is 
by  far  the  commonest  condition.  Anything  from  a  very  mild  to  a 
severe  catarrhal  condition  is  accompanied  by  mucus. 

(c)  Fresh  Blood. — Piles  are  by  far  the  commonest  cause  of 
bloody  stools,  and  the  amount  of  blood  may  be  trifling  or  may  be 
large  enough  to  produce  in  time  a  severe  anaemia. 

Enteritis  (the  mild  follicular  or  the  severe  ulcerative  form) 
often  produces  bloody  stools.  The  associated  symptoms,  diar- 
rhoea, mucus,  and  pain,  together  with  the  etiology  (dietetic  error, 


406  PHYSICAL  DIAGNOSIS. 

typhoid  fever,  amoeba  coli),  must  determine  the  nature  of  the  en- 
teritis. 

In  cancer  of  the  rectum  or  sigmoid  (rarely  higher  up  in  the 
bowel),  small  quantities  of  blood,  fresh  or  altered,  are  almost 
always  passed  sooner  or  later.  The  infrequent,  offensive,  and  pain- 
ful stools  and  the  results  of  digital  examination  usually  reveal  the 
source  of  the  blood. 

In  intussusception  the  association  of  bloody  stools  with  the  sud- 
den appearance  of  a  painful  abdominal  tumor  (usually  in  the  caecal 
region),  vomiting,  and  severe  constitutional  manifestations  suggest 
the  diagnosis. 

In  hemorrhagic  diseases  (purpura,  scurvy,  acute  leukaemia)  blood 
may  come  from  the  intestine  as  well  as  from  the  other  mucous  mem- 
branes. Other  rare  causes  for  blood  in  stools  are  a  ruptured  aneur- 
ism, thrombosed  mesenteric  artery,  rectal  syphilis,  or  fissure. 

(d~)  Altered  blood  (tarry  stools,  melaena)  follows  the  pouring  out 
of  blood — a  pint  or  more — in  the  upper  gastro-intestinal  tract,  and 
occurs  in  hepatic  cirrhosis,  gastric  or  duodenal  ulcer,  after  severe 
nose-bleed,  and  occasionally  from  other  causes.  Occult  blood,  rec- 
ognizable by  the  guaiac  test,  often  occurs  in  cancer  or  ulcer  of  the 
stomach,  and  forms  an  important  link  in  the  chain  of  evidence  on 
which  the  diagnosis  of  those  diseases  is  based. 

(e)  Pus  is  not  of  great  diagnostic  value.  Large  amounts  mean 
the  breaking  of  an  abscess  (appendix,  pus  tube)  into  the  rectum. 
Small  amounts  occur  in  ulcers  or  even  from  catarrh. 

(/)  Shreds  of  tissue  point  to  ulceration. 

(g)  Gall  Stones. — In  suspicious  cases  break  up  the  faeces  in  a 
sieve  with  plenty  of  water.  The  peculiar,  facetted  shape  of  most 
gall  stones  is  easily  recognized. 

Intestinal  Parasites. 

Bacteria. — Only  the  tubercle  bacillus  can  be  recognized  without 
culture  methods,  which  do  not  fall  within  the  scope  of  this  book. 

For  the  identification  of  tubercle  bacilli  the  following  method  is 
to  be  recommended :  "  Dilute  the  stool  with  ten  volumes  of  water, 
mix  thoroughly,  and  let  it  stand  in  a  wide-mouthed  bottle  for 


CABOT    PHYSICAL    DIAGNOSIS. 


PLATE   I. 


!  x 


FKJ.  1.— Trichomonas  hominis.     (Leuokart.) 


FIG.  2.  — Balantidium  coli.     (Leuckart.)    Magnified  about  l.V)  diameters. 


FIG.  .{.— Lamhlia  int^tmHlis.     (Leuckart.) 


THE  INTESTINE,   SPLEEN,    KIDNEY.  407 

twenty-four  hours.  The  narrow  layer  between  the  thin  supernatant 
liquid  and  the  solid  sediment  contains  the  bacilli.  Remove  this 
with  a  pipette,  spread  it  on  a  cover  slip,  evaporate  slowly  to  dry- 
ness,  and  proceed  as  with  sputum  "  ("  Harvard  Outlines  of  Medical 
Diagnosis,"  1904,  p.  29). 

Animal  Parasites. 

The   most  important  are  : 

1.  Amoeba  coli. 

I.  Serious •{  0    TT.^|,  ,  j  (a)  Uncinaria  americana. 

i  (b)  Anchylostoma  duodenale. 

3.  Tape-worms:  the  beef- worm  (Taenia  saginata) is  very 

common;  the  pork-worm  (Tsenia  solium)  is  rare; 
the   miniature  tape-worm  (Taenia  nana)  and  the 
„  .  fish-worm   (Dibothriocephalus  latus1)  are    fairly 

11.  Kelariveiy  ,  common.     Several  other  forms  occur  in  foreign 

mild-  countries. 

4.  Strongyloides  intestinalis. 

5.  Balantidium  coli. 

6.  Bilharzia  hamatobium. 

f    7.  Ascaris  lumbricoides  (round-worm). 

TTT    T^       n        [     8.  Oxyuris  vermicularis  (thread-worm;  pin-worm). 
.11.   usually     ^     9    Trichiuris  tl.iclliura  (whip-worm). 

-ss'  I  10.  Trichomonas  intestinalis. 
1. 11.  Lamblia  intestinalis. 

Tape-worms,  round-worms,  pin-worms,  and  the  Strongyloides 
are  to  be  recognized  in  their  adult  form  (see  Figs.  183,  184,  185, 
186,  187).  They  are  usually  noticed  by  the  patients  themselves 
and  brought  to  the  physician  for  examination.  If  the  worm  has  the 
look  of  a  common  earth-worm,  but  a  length  of  five  to  nine  inches, 
it  is  safe  to  call  it  the  "  round-worm  "  (Ascaris  lumbricoides);  if  the 
worm  is  about  one-half  an  inch  long  and  as  thick  as  a  pin,  it  is  in 
all  probability  a  "pin- worm  "  (Oxyuris  vermicularis). 

The  Amcela  coli  is  to  be  searched  for  in  fresh  stools  passed  into 
a  warm  vessel.  A  bit  of  mucus  from  such  stools  is  put  upon  a 
warmed  slide  with  a  drop  of  water,  covered  with  a  cover  glass,  and 
examined  at  once  with  a  high-power  dry  lens.  It  is  recognized  by 

1  Fish  tape-worms  may  produce  a  severe  anaemia,  but  in  probably  the 
great  majority  of  all  cases  they  do  not  do  so. 


408 


PHYSICAL  DIAGNOSIS. 


the  presence  of  distinct  amoeboid  movements.1  When  dead  it  assumes 
a  round  shape,  but  one  should  not  attempt  a  positive  diagnosis  un- 
less live  amoeboid  parasites  are  present. 

The  other  parasites  are  identified,  as  a  rule,  by  the  finding  of 
their  eggs  in  the  stools.  The  technique  of  this  operation  is  de- 
scribed below,  as  exemplified  in  the  search  for  the  egg  of  uncina- 
ria — at  present  the  egg  most  important  for  Americans  to  recognize. 

Eggs  of  parasites  catch  the  eye 
in  the  examination  of  stools,  first  of 
all,  by  the  clean-cut,  mathematical 
symmetry  of  their  oval,  when  com- 


Fio.  183.— a.  Head  of  Taenia  saginata,  much  magnified ;   b,  uterine  canal  of  same.    About 
twenty  branches  on  each  side. 

pared  with  the  irregular,  shapeless  masses  which   usually  appear 
in  slide  and  cover  preparations  from  the  faeces. 

Secondly,  the  size  of  parasitic  eggs  is  greater  than  that  of  most 
of  the  objects  seen  in  the  faeces;  and,  thirdly,  they  are  for  the  most 
part  dark  brown,  stained  with  bile  (the  uncinaria  is  an  exception). 

The  differences  between  individual  species  will  be  described 
later.  In  Plates  II.  and  III.  the  most  important  eggs  are  pictured 
and  catalogued. 

1  See  Appendix  F. 


CABOT-PHYSICAL    DIAGNOSIS. 


PLATE    II. 


t  / 


liistoma  i>iiski. 


Asraris  lumhricohles. 


I'lii-iiiiiria  i 


Aucbylofitoina  duoilenale. 


Trii-buris  tru-hiui-a. 


latus. 

K(i(-S   OF   INTESTINAL    PARASITES. 
All  arc  magnified  2-"iO  diameters. 


'I'ii'iiia  siiliiun.  TH-iila  siijrinata. 


THE  INTESTINE,   SPLEEN,    KIDNEY. 


409 


The  Uncinaria  americana  or  its  European  equivalent  (Anchylos- 
toma  duodenale)  is  recognized  most  easily  by  the  identification  of  its 
eggs  in  the  stools.  These  eggs  are  characteristic  (see  Plate  II. ), 
and  "  the  only  thing  liable  to  be  confounded  with  them  is  the  ovum 
of  Ascaris  lumbricoides  stripped  of  its  heavy,  bile-stained  outer 
shell  (see  Plate  II.);  but  this  has  a 
double  contour  and  contains  a  shapeless 
mass  of  granular  matter  not  differen- 
tiated" (as  most  uncinaria  eggs  are) 
"into  clear  segments."1  The  greater 


FIG.  184.— a.  Head  of  Taenia  solium  (ncle  crown  of  hooks) ;  b,  uterine  canal  in  two  segments. 
Only  flve  to  seven  branches  on  each  side. 


size  of  the  American  hook-worm's  egg  compared  to  that  of  the 
European  worm  is  shown  in  Plate  II.  "  Free  embryos  are  rarely 
if  ever  found  in  intestine.  When  free  (worm-like)  embryos  are 
seen  in  the  stools,  they  are  generally  those  of  the  Strongyloides  in- 
testinalis  "  (see  Fig.  187). 

1  All  the  quotations  in  this  section  are  from  the  "  Report  of  the  Commis- 
sion for  the  Study  and  Treatment  of  Anaemia  in  Porto  Rico,"  by  Asuford, 
King,  and  Igaravidez  (December  1st,  1904),  a  study  of  5,490  cases. 


410 


PHYSICAL  DIAGNOSIS. 


The  ova  of  uncinaria  catch  the  eye  in  a  rapid  examination, 
first,  because  they  are  "  not  generally  bile- stained,  but  clear,  whereas 
those  of  the  commonly  associated  intestinal  parasites  are  of  a  yel- 
low to  deep  amber  or  brown  color." 
They  are  distributed  quite  evenly 
throughout  the  entire  faecal  mass; 
hence,  ill  searching  for  them,  the 
following  method  is  advisable : 

Technique  of  Microscopic  Exami- 
nation.— "  A  bit  of  faeces  the  size  of  a 
match  head  is  removed  with  a  tooth- 
pick and  placed  on  a  glass  slide. 
Upon  this  is  placed  a  cover  glass 
and  pressed  down  so  as  to  give  a  clear 


FIG.  185.— Tsenia  nana  (Dwarf  Tape-worm),    a.  Booklet;  b,  head,  greatly  enlarged;  c,  whole 
worm,  magnified  about  10  times. 


centre  to  the  specimen.  Do  not  add  water.  Examine  with  a  one- 
third  to  two-thirds  objective,  a  No.  4  ocular,  and  a  partially  closed 
diaphragm.  If  too  much  light  is  admitted  the  delicate  ovum  will 
be  passed  over." 


THE  INTESTINE,   SPLEEN,   KIDNEY. 


411 


The  following  interesting  table  (from  the  studies  of  Ashford, 
King,  and  Igaravidez  in  Porto  Rico)  shows,  roughly,  the  relative 
frequency  (in  a  tropical  climate)  of  the  common  intestinal  parasites 


Fro.  186.— Segments  of  the  Dlbothriocephalus  latus  (Fish  Tape-worm), 
shaped  uterine  marking. 


Note  the  rosette- 


recognizable  by  their  eggs.     In  the  examination  of  the  stools  of 
5,490  cases  of  uncinariasis  they  found  as  well: 

Ascaris  lumbricoides  in 1,408  (many  others  seen  but  not  noted). 

Trichuris  trichiura  in 326  (many  others  seen  but  not  noted). 


Strongyloides  intestinalis  in. 
Bilharzia  hsematobium  in. . , 


Balantidium  coli  in 

Oxyuris  vermicularis  in. ... 

Amoeba  coli  in 

Taenia  saginata  in 

Taenia  solium  in. . 


36  (the  embryo  worms,  not  eggs). 
21  (frequently    no    careful    search 

was  made  for  this  egg). 
14 

3 

3 

2 

2 


Ascaris  lumbricoides  has  usually  a  thick,  wavy  ("  mammillated  ") 
shell;  but  this  is  not  always  seen,  and  in  its  absence  the  egg  is  dis- 
tinguishable from  Uncinaria  americana  chiefly  by  the  absence  of 
the  segmentation  usually  seen  in  the  egg  of  the  latter  (see  Plate 

EL,  a> 

Trichuris  trichiura  (also  called  Tricocephalus  dispar)  has  a  thick 
shell,  very  dark-stained,  and  apparently  pointed  and  perforated  at 


412 


PHYSICAL  DIAGNOSIS. 


each  end,  instead  of  curving  evenly  over  as  the  uncinaria  egg  does 

(see  Plate  II.,  c). 

Bilharzia  eggs  are  not  at  all  uncommon  in  the  faeces,  though 
more  often  described  in  the  urine,  in  con- 
nection with  haernaturia.  The  terminal 
spine  at  one  end  is  their  most  character- 
istic feature  (see  Plate  II.,  d). 

The  other  eggs  are  briefly  described  in 
the  explanatory  text  accompanying  Plate 
II. 

THE  SPLEEN. 

Diseases  of  the  spleen  (abscess,  malig- 
nant disease)  are  almost  never  recognized 
during  life.  It  is  for  evidence  of  splenic 
enlargement  as  a  factor  in  the  diagnosis  of 
diseases  originating  elsewhere  that  we  in- 
vestigate the  splenic  region  as  part  of  the 
routine  of  abdominal  examinations. 

Splenic  enlargement  is  detected  chiefly  by 
palpation.  Percussion  plays  a  minor  role 
in  the  determination  of  the  organ's  size, 
and  should  never  be  relied  on  in  the  absence 
of  palpable  evidence.  Palpation  is  easy, 
provided  the  organ  is  enlarged  sufficiently 
to  project  beyond  the  ribs  without  forced 
respiration,  but  much  practice  is  needed 
when  the  enlargement  is  slight,  as  in,  for 
example,  most  cases  of  typhoid  fever. 

Palpation  of  the  Spleen. 


FIG.  187.— Stronjryloldes  ster- 
coralis.  Magnified  about  250 
diameters.  (After  Thayer.) 


The  co-operative  action  of  both  hands 
is  as  essential  as  in  vaginal  examination,  and 
each  hand  must  do  the  right  thing  at  the  right 


CABOT-PHYSICAL    DIAGNOSIS. 


Heterophyes 
heterophyes. 


PLATE    III. 


Bilhiirxia 
htrinatobium. 


Ascaris 
luinhrif'oic'ps. 


Ancbylootoma 

duodeiiale. 


I)iplo£onoporus 
jrrandis. 


Bilharzia 
haematobium. 


Dibothrto- 

cephalus  latus. 


Paraironiinus 
westennani. 


Ta?nia  nana. 


Bilharzia 
hasinatobium. 


Ascaris 
hinihriroides. 


f 


Strongyloides 
stci-coralis. 

DRAWINGS   OF   EGGS   OF  INTESTINAL  PARASITES. 
All  are  nmgrniHe<l  250.     (After  Looss). 


Triehuris 
trichiura. 


THE  INTESTINE,   SPLEEN,   KIDNEY. 


413 


moment.  The  patient  should  be  on  his  back,  his  head  comfortably 
supported  and  his  knees  drawn  up.  The  left  hand,  placed  over  the 
normal  situation  of  the  spleen,  (a)  draws  the  whole  splenic  region 
downward  and  inward  toward  the  expectant  finger-tips  of  the  right 
hand;  (6)  at  the  same  time  the  left  hand  should  slide  the  skin  and 


j 

FIG.  188.— Position  of  the  Hands  in  Palpation  of  the  Spleen. 

subcutaneous  tissues  over  the  ribs  and  toward  the  right  hand  (see 
Fig.  188),  so  as  to  leave  a  loose  fold  of  skin  along  the  margin  of  the 
ribs  and  give  the  palpating  ringers  a  slack  rather  than  a  taut  cover- 
ing to  feel  through. 

The  right  hand  lies  on  the  abdominal  wall  just  below  the  margin 
of  the  ribs,  and  the  lingers  should  point  straight  up  the  path  down 
which  the  spleen  is  to  move,  i.e.)  obliquely  toward  the  left  hypo- 
chondriuin.  With  the  hands  in  this  position  ask  the  patient  to 
draw  a  full  breath.  Keep  the  hands  still  and  do  not  expect  to  feel 
anything  until  near  the  end  of  inspiration.  Then  draw  the  hands 
slightly  toward  each  other  and  dip  in  a  little  with  the  right  finger- 
tips, so  that  if  the  spleen  issues  from  beneath  the  ribs  its  edge  will 
meet  the  finger-tips  for  an  instant  and  spring  over  them  as  they 
rise  from  diving  into  the  soft  tissues  (see  Fig.  188). 

Some  physicians  have  the  patient  lie  on  the  right  side,  and. 


414  PHYSICAL  DIAGNOSIS. 

standing  behind  him,  hook  their  fingers  over  the  ribs  in  the  left 
hypochondrium.  In  this  way  we  may  be  able  to  feel  the  spleen  at 
the  end  of  a  long  inspiration,  but  I  have  seldom  found  this  position 
as  useful  as  that  described  above. 

A  hard,  fibrous  spleen  (malaria)  is  much  easier  to  feel  than  a 
soft  one  (typhoid). 

Percussion  of  the  Spleen. 

Only  when  the  edge  of  the  spleen  has  been  felt  is  it  worth  while 
to  try  to  define  its  upper  border  by  percussion.  Normally  there  is 
dulness  in  the  midaxillary  line  from  the  ninth  to  the  eleventh  ribs, 
corresponding  to  that  part  of  the  spleen  that  is  most  superficial. 
Its  lower  and  posterior  borders  cannot  be  defined;  its  anterior  edge 
is  approximately  in  the  midaxillary  line  (see  Fig.  38).  If  this 
small  area  of  dulness  is  enlarged  upward  and  forward,  and  if  the 
edge  has  been  felt  below  the  ribs,  it  is  probable  that  the  increased 
area  of  dulness  corresponds  to  an  enlargement  of  the  organ. 

Causes  of  Splenic  Enlargement. 

Slight  enlargement  of  the  spleen  can  often  be  detected  in : 

1.  Rickets  and  other  debilitating  conditions  of  childhood  with  or 
without  anaemia. 

2.  Malaria. 

3.  Typhoid  fever. 

In  other  acute  infections    slight    enlargement  can   usually  be 
nade  out  post  mortem,  but  not  during  life. 
Marked  enlargement  (chronic)  occurs  in: 

1.  Chronic  malaria — 8  per  cent  of  my  series. 

2.  Hepatic  cirrhosis — 30  per  cent  of  my  series. 

3.  "  Splenic  anaemia  " — 4  per  cent  of  my  series. 

4.  Leukaemia  (of  any  type) — 35  per  cent  of  my  series. 

5.  Hodgkin's  disease — 6  per  cent  of  my  series. 

6.  Amyloid — .1  per  cent  of  my  series. 

7.  Without  known  cause  ("  primary  "  or  "  idiopathic  "  spleno- 
megaly)— 12  per  cent  of  my  cases. 

Rare  causes  are  abscess,  tuberculosis,  malignant  disease,  perni- 


THE  INTESTINE,  SPLEEN,   KIDNEY.  415 

cious  anaemia,  polycythsemia,  hydatid,  syphilis,  and  Leishman- 
Donovan  disease.  Together  these  make  4  per  cent  of  my  series. 

Differences  Between  a  Large  Spleen  and  Tumors  (of  the  kidney  or 
other  organs). — A  large  spleen  is  easily  recognized  after  a  little 
practice.  As  it  enlarges  it  keeps  its  shape  and  advances  obliquely 
across  the  belly  toward  the  navel  or  (in  marked  cases)  beyond  it. 

It  is  always  hard  and  smooth  of  surface,  although  the  edge  near- 
est the  epigastrium  shows  one  or  more  notches  which  are  very  char- 
acteristic. The  edge  is  sharp,  never  rounded,  and  the  whole  organ 
is  very  superficial,  being  covered  only  by  the  belly  walls,  so  that  if 
we  inflate  the  colon  (by  forcing  air  into  the  rectum  with  a  Davidson 
syringe),  it  passes  behind  the  spleen  and  does  not  obliterate  its  dul- 
ness. 

Tumors  of  the  kidney  fill  out  the  flank,  and  an  impulse  can  be 
transmitted  to  the  lumbar  region  by  bimanual  palpation.  They 
have  no  sharp  edge  or  notches,  are  often  irregular  of  surface,  and 
not  so  superficial.  The  inflated  colon  passes  in  front  of  a  tumor  of 
the  kidney  and  obliterates  the  dulness  due  to  it. 

All  these  differences  hold  for  any  other  tumors  likely  to  be  con- 
fused with  an  enlarged  spleen. 

Differential  Diagnosis  of  the  Various  Causes  of  Splenic 
Enlargement. 

In  children  splenic  enlargement  without  fever  or  leukaemic  blood 
changes  is  to  be  classed  as  a  manifestation  of  general  debility.  It 
has  no  special  connection  with  any  type  of  anaemia,  though  anaemia 
is  often  seen  with  it. 

In  typhoid  the  fever  and  the  Widal  reaction  are  generally  suffi- 
cient to  make  clear  the  cause  of  the  splenic  enlargement;  in  active 
malaria  the  blood  parasites  are  always  demonstrable,  and  in  chronic 
cases  the  history  and  the  locality  are  significant. 

Hepatic  cirrhosis  (and.  Banti's  disease)  should  show  evidences  of 
portal  stasis  (ascites,  jaundice,  haematemesis). 

Splenic  anoemia  means  simply  an  anaemia  of  unknown  origin 
associated  with  an  enlarged  spleen. 

Leukcemic  enlargement  of  the  spleen  is  easily  recognized  by  the 
characteristic  blood  picture. 


416  PHYSICAL  DIAGNOSIS. 

Hodgkin's  disease  shows  glandular  enlargements  in  the  neck, 
axillae,  and  groins,  with  normal  blood.  Histological  examination 
of  an  excised  gland  is  necessary  for  diagnosis. 

Amyloid  can  be  suspected  (never  positively  diagnosed)  as  the 
cause  of  an  enlarged  spleen,  if  there  is  a  history  of  syphilis  or 
chronic  suppuration  (hip  abscess,  phthisis,  etc.}. 


DISEASES  OF  THE  KIDNEY. 

Incidence  of  Renal  Disease  (^Massachusetts  General  Hospital)  1870- 

1905). 

Acute  nephritis 200 

Chronic  glomerulo-nephritis 417 

Chronic  interstitial  nephritis 250  * 

Amyloid  nephritis 9 

Floating  kidney 227 

Stone  in  the  kidney 145 

Malignant  disease .*. 42 

Tuberculous  kidney 41 

Pyonephrosis  and  abscess 54 2 

Perinephritic  abscess 35 

Hydronephrosis 19 

Cystic  kidneys 10 

Total 1,449 

We  get  evidence  of  diseases  of  the  kidney  in  four  ways : 

1.  By  external  examination  of  the  region  of  the  kidney. 

2.  By  examination  of  the  urine. 

3.  By  cystoscopy  and  the  ureteral  catheter. 

4.  By  study  of  the  constitutional  symptoms — fever,  leucocyto- 
sis,  anaemia,  uraemia,  dropsy,  cardiac  hypertrophy. 

Local  examination  acquaints  us  with  the  presence  of  tenderness 
and  tumor. 

(a)  Tenderness  is  present  usually  in  abscess  of  the  kidney  (tu- 
berculous or  non-tuberculo\is)  and  in  perinephritic  abscess,  less 
often  in  connection  with  nephrolithiasis,  occasionally  in  hydrone- 

1  Seven  hundred  and  seventy-five  other  cases  of  "  nephritis  "  not  further 
specified. 

2  Including  acute  hscmatogenous  cases. 


THE  INTESTINE,  SPLEEN,  KIDNEY.  417 

phrosis  and  malignant  disease.  A  floating  kidney  may  have  an 
exquisite  and  peculiar  sensitiveness  to  pressure,  which  differs  from 
ordinary  tenderness. 

(£)  Tumor  in  the  kidney  region  may  occur  in  abscess  in  or 
around  the  kidney  (including  tuberculosis  of  the  kidney  and  pyo- 
nephrosis),  malignant  disease,  hydronephrosis,  and  cystic  kidney. 
The  latter  members  of  this  list  afford  examples  of  the  largest  tu- 
mors associated  with  the  kidney. 

Characteristics  Common  to  Most  Tumors  of  the  Kidney. 

Kenal  tumors  are  best  felt  bimanually,  one  hand  in  the  hypo- 
chondriuni  and  the  other  in  the  region  of  the  kidney  behind,  with 
the  patient  in  the  recumbent  position.  In  this  way  the  tumor  may 
often  be  grasped  and  an  impulse  transmitted  from  hand  to  hand. 
It  is  usually  round  and  smooth,  often  very  hard,  less  often  fluctu- 
ating. It  descends  slightly  with  inspiration.  If  the  colon  is  in- 
flated by  forcing  air  into  the  rectum  with  a  Davidson  syringe,  res- 
onance appears  in  front  of  the  tumor;  this  serves  to  distinguish  it 
from  tumors  of  the  spleen  which  are  pushed  forward  by  the  inflated 
colon  as  it  passes  behind  them.  Tumors  of  the  kidney  never  pre- 
sent a  thin  and  sharp  edge,  like  that  of  the  spleen.  Occasionally 
they  are  irregular  and  nodulated — a  condition  almost  never  found 
in  the  spleen. 

(a)  Malignant  disease  of  the  kidney,  sarcoma,  or  hypernephroma, 
is  much  commoner  in  children  than  in  adults,  and  makes  up  the  great 
bulk  of  the  large  abdominal  tumors  occurring  in  childhood.      The 
characteristics  of  the  tumor  are  those  already  described,  except  that 
in  advanced  stages  the  tumor  pushes  forward  from  its  position  in 
the  loin  until  it  may  reach  the  umbilicus  or  even  till  the  abdomen. 
Nodular  irregularities  can  usually  be  felt.     There  may  be  haematu- 
ria,  emaciation,  and  anaemia,  sometimes  leucocytosis.     Metastases 
— especially  bone  metastases — are  often   the  first  evidence  of  the 
disease. 

(b)  Hydronephrosis  and  cystic  kidney  may  be  indistinguishable 
from  each  other  unless  the  hydronephrosis  is  intermittent  and  dis- 
appears with  a  great  gush  of  urine,  or  unless  the  cystic  kidney  is  bi- 
lateral— as,  indeed,  is  usually  the  case.     In  both  diseases  a  smooth, 

27 


\ 


418 


PHYSICAL  DIAGNOSIS. 


round  tumor  forms  in  the  loin  and  hypochondriuni,  usually  without 
much  constitutional  disturbance  and  very  frequently  with  a  urine 
like  that  of  chronic  interstitial  nephritis  (see  below)  (see  Fig.  189). 
Pain  and  tenderness  are  slight.  The  tumor  may  be  astonishingly 
hard  and  often  gives  no  sign  of  fluctuation.  With  cystic  kidney  it 
may  be  coarsely  lobulated.  Like  other  tumors  of  the  kidney  it  de- 
scends slightly  on  inspiration.  Cystic  kidneys  are  often  congenital, 
but  usually  produce  no  symptoms  until  they  have  attained  a  consid- 
erable size,  and  hence  are  often  overlooked  or  discovered  accident- 
ally. In  hydronephrosis  the  diagnosis  may  be  assisted  by  etiological 

hints,  such  as  an  abnormal  degree 
of  mobility  of  the  kidney  on  the 
affected  side,  a  history  of  renal 
colic  with  or  without  hcematuria, 
or  a  prostatic  obstruction. 

(«)  Perinephritic  abscess  usually 
works  its  way  to  the  surface  in  the 
back,  between  the  crest  of  the  ilium, 
and  the  twelfth  rib.  This  was  the 
situation  of  the  external  tumor  in 
25  out  of  35  cases  recorded  at  the 
Massachusetts  General  Hospital. 
A  tender  swelling  appears  at  the 
point  just  described,  sometimes 
with  redness  and  heat,  and  almost 
always  with  fever,  chills,  leuco- 
cytosis,  and  some  emaciation.  The 
urine  may  show,  nothing  abnormal 
or  may  show  the  evidence  of  cys- 
titis, of  concomitant  nephritis,  or, 

rarely,  of  an  abscess  within  the  kidney  itself.  Perinephritic  ab- 
scess often  remains  latent  for  weeks  or  months,  and  the  amount  of 
pus  accumulated  may  be  a  quart  or  more. 

(</)  Abscess  of  the  kidney,  including  tuberculous,  suppurating  kid- 
neys and  pyonephrosis,  usually  produces  a  smooth,  round  tumor  in 
the  hypochondrium  and  loin.  It  has  the  characteristics  common  to 
most  renal  tumors  (see  last  page),  but  is  usually  distinguishable  by : 


FIG.  189.— Left  Hydronephrosis. 


THE  INTESTINE,   SPLEEN,  KIDNEY.  419 

1.  The  etiology  (cystitis,  stone  in  the  kidney,  tuberculosis,  pyae- 
mia).    In  acute  cases,  however,  there  is  often  no  discoverable  cause. 

2.  The  presence  of  renal  pyuria  (see  below,  page  423;. 

3.  The  presence  of  fever,  leucocytosis,  and  the  usual  constitu- 
tional signs  of  an  infectious  process. 

(e~)  Floating  Kidney  ;  Displaced  and  Movable  Kidney.  —  The  tip 
of  the  right  kidney  is  palpable  in  most  thin  persons  with  loose  belly 
walls.  If  the  whole  organ  is  palpable  but  not  movable,  we  speak 
of  it  as  displaced.  If  the  range  of  mobility  is  relatively  great  we 
call  \^  floating  ;  if  relatively  slight  we  call  it  movable.  With  biman- 
ual  palpation  (as  described  above)  we  exert  pressure  just  at  the  end 
of  a  deep  inspiration  and  maintain  it.  During  expiration  something 
smooth  and  round  may  then  be  felt  to  slip  upward  between  our 
hands  toward  the  ribs.  If  the  kidney  "  hides  "  behind  the  ribs, 
have  the  patient  sit  up,  cough,  and  breathe  deeply;  then  repeat  the 
bimanual  palpation  as  he  lies  on  his  back.  Very  movable  or  float- 
ing kidneys  may  be  found  far  from  their  normal  home,  and  are  then 
recognized  by :  1.  Their  size,  shape,  and  slippery  feel.  2.  The 
sickening  pain  produced  by  pressure.  3.  The  possibility  of  replac- 
ing them. 

Renal  Colic  and  Other  Renal  Pain. 

Typical  renal  colic  is  paroxysmal,  like  all  colics;  that  is,  an  at- 
tack begins  suddenly,  ends  suddenly,  and  lasts  but  a  few  hours  or 
less.  The  pain  usually  begins  in  the  back,  over  the  kidney,  and 
follows  the  course  of  the  ureter  to  the  groin.  During  an  attack  the 
testicle  on  the  affected  side  may  be  tender  and  drawn  up  tightly  by 
contraction  of  the  cremaster. 

When  associated  with  hsematuria  or  pyuria,  with  or  without  sud- 
den stoppage  of  water  during  an  attack  and  without  any  general  or 
constitutional  symptoms  between  attacks,  renal  colic  is  strongly  sug- 
gestive of  stone  in  the  pelvis  of  the  kidney;  but  similar  attacks  may 
occur  with  other  surgical  diseases  of  the  kidney,  with  tuberculosis, 
with  kinking  of  the  ureter,  and  very  often  without  any  cause  dis- 
coverable at  operation. 

From  biliary  colic  it  may  be  distinguished  by  the  (a)  different 
27 


420  PHYSICAL  DIAGNOSIS. 

situation  of  the  pain,  (6)  by  the  presence  of  blood  or  pus  in  the 
urine,  and  (c)  the  absence  of  jaundice  in  this  or  a  former  attack. 

From  DietVs  crisis  (severe  colicky  pain  occurring  in  connection 
with  floating  kidney),  renal  colic  is  distinguished  by  the  absence  of 
abnormal  mobility  of  the  kidney  and  by  the  situation  and  course  of 
the  pain. 

In  intestinal  colic  the  pain  shifts  its  position  frequently  and  is 
associated  with  noises  produced  by  wind  in  the  bowels,  or  with  diar- 
rhoea or  constipation. 

Renal  pain,  not  colic,  occurs  in  almost  any  disease  of  the  kidney 
except  nephritis,  and  is  characterized  by  its  situation  over  the  ana- 
tomical seat  of  the  kidney  and  by  the  lack  of  any  connection  with 
muscular  movements  (lumbago),  with  spinal  movements  (hypertro- 
phic  arthritis),  or  with  the  sacro-iliac  joint. 

I  have  now  described  what  seems  to  me  most  important  in  the 
local  external  examination  for  kidney  disease,  and  have  mentioned, 
along  with  the  different  lesions  producing  tumor,  the  general  con- 
stitutional manifestation's  which  are  of  assistance  in  diagnosis. 
Aside  from  the  local  and  the  constitutional  evidence  of  renal  disease, 
we  have  only  the  evidence  afforded  by  the  urine,  to  which  I  now 
pass  on. 

Examination  of  the  Urine. 

The  urine  as  passed  per  urethram  is  a  resultant  and  reflects  the 
influence  of  many  different  organs  and  surfaces.  Thus  disturb- 
ances of  metabolism,  such  as  diabetes,  intoxications  (lead,  arsenic), 
diseases  of  the  heart,  liver,  and  intestine,  febrile  conditions,  infec- 
tive or  malignant  disease  of  any  part  of  the  urinary  tract  (kidney, 
ureter,  bladder,  or  urethra),  as  well  as  the  different  types  of  ne- 
phritis, all  affect  the  urine,  though  hardly  any  of  them  produce 
pathognomonic  changes  in  it.  In  this  section  I  shall  consider  the 
urine  as  a  piece  of  evidence  in  the  diagnosis  of  kidney  disease,  and 
only  in  contrast  with  this  will  its  characteristics  in  extrarenal 
troubles  be  mentioned  briefly. 

The  most  essential  features  of  the  urine  in  the  diagnosis  of  kid- 
ney disease  are : 

1.  The  amount  passed  in  twenty-four  hours,  measuring  sepa- 


THE  INTESTINE,    SPLEEN,    KIDNEY.  421 

rately  the  portions  passed  at  night  (8  P.M.  to  8  A.M.)  and  in  the 
daytime  (8  A.M.  to  8  P.M.). 

2.  The  specific  gravity. 

3.  The  looks  (optical  properties). 

4.  The  reaction  to  litmus. 

Much  less  important  than  these  are  the  microscopic  and  chemi- 
cal examinations  (albumin,  casts,  etc.). 

The  Amount  and  Weight  of  the  Urine. 

The  twenty-four-hour  amount  concerns  us  chiefly  in  diabetes  and 
the  different  types  of  nephritis. 

Polyuria  occurs  in  health  after  the  ingestion  of  large  quantities 
of  water,  and  sometimes  in  conditions  of  nervous  strain.  In  dis- 
ease it  characterizes  both  forms  of  diabetes,  cirrhotic  kidney  (pri- 
mary, secondary,  or  arterio-sclerotic) ,  and  is  seen  during  the  con- 
valescence from  acute  nephritis  and  from  various  infectious  diseases. 
In  diabetes  of  either  form  several  quarts  or  even  gallons  may  be 
passed.  In  cirrhotic  kidney  the  increase  of  urine  occurs  very  largely 
at  night,  so  that  the  amount  may  be  double  that  passed  in  the  day- 
time, just  reversing  the  conditions  of  health. 

Oliguria  or  scanty  urine  occurs  in  health  when  the  amount  of 
water  ingested  is  small  or  when  water  is  passed  out  of  the  body 
abundantly  through  the  skin  or  by  the  bowels  (diarrhoea).  In  dis- 
ease oliguria  or  absolute  suppression  of  urine  (anuria)  occurs  at  the 
beginning  of  acute  nephritis  and  as  a  result  of  occlusion  of  one  or 
both  ureters  by  stone  or  malignant  disease.  *  Remarkable  examples 
of  anuria  also  occur  in  hysteria.  Infectious  fevers  and  cachectic 
states  often  diminish  the  secretion  of  the  urine  by  one-half  or  more. 

The  specific  gravity  is  usually  low  with  polyuria  and  high  with 
oliguria,  but  in  diabetes  mellitus  the  presence  of  the  sugar  gives  us 
polyuria  with  high  specific  gravity. 

Total  Urinary  Solids. — By  multiplying  the  last  two  figures  of 
the  specific  gravity  by  the  number  of  ounces  of  urine  passed  in 

1  It  is  a  remarkable  but  well-attested  fact  that  when  one  ureter  is  suddenly 
blocked  both  kidneys  may  stop  secreting  for  the  time.  Yet  when  one  kid- 
ney is  gradually  destroyed  as  in  tuberculosis,  the  other  hypertrophies  so  as 
to  assume  the  function  of  both. 


422  PHYSICAL  DIAGNOSIS. 

twenty-four  hours  and  the  product  by  1.1,  we  get  a  figure  represent 
ing  the  total  urinary  solids  in  grains,  with  accuracy  sufficient  foi 
clinical  diagnosis.  Thus  if  30  ounces  of  urine  are  passed  in  24 
hours  and  the  gravity  is  1.020,  then  20  x  30  x  1-1  =  660  grains. 
The  significance  of  this  figure  will  be  discussed  later  (see  page  428). 

_     Optical  Properties. 

Color. — Dilute  urines  (polyuria)  are  generally  pale,  and  concen- 
trated urines  (oliguria)  high  in  color.  A  dark  or  brownish  tint  in 
the  urine  is  generally  produced  by  bile,  by  blood  pigment,  or  as  a 
.result  of  certain  drugs — carbolic  acid,  coal-tar  preparations,  and 
salol.  If  the  color  is  due  to  bile,  a  bright  canary  yellow  appears  in 
the  foam  after  shaking  up  a  little  of  the  urine  in  a  test  tube.  No 
other  tests  for  bile  are  necessary.  Urines  darkened  by  blood  pig- 
ment show  abundant  blood  corpuscles  in  the  sediment ; '  when  the 
color  is  due  to  drugs  we  can  usually  learn  this  fact  from  the  his- 
tory. 

Turbidity  in  alkaline  urine  is  usually  due  to  the  presence  of  bac- 
teria. In  acid  urine  it  is  produced  in  a  great  majority  of  cases  by 
amorphous  urates,  and  disappears  on  heating  the  urine,  while  the 
turbidity  due  to  bacteria  is  unaffected  by  heat.  Normal  urine  may 
be  turbid  and  alkaline,  owing  to  the  presence  of  insoluble  carbo- 
nates and  phosphates,  but  clears  on  the  addition  of  acetic  acid. 
Hence  turbidity,  not  removed  by  heat  or  acetic  acid,  is  almost 
always  due  to  bacteria,  i.e.,  to  cystitis,  pyelonephritis,  or  both. 

Shreds  seen  floating  in  the  urine  are  presumptive  evidence  of 
urethritis,  and  practically  always  of  gonorrhoea. 

The  gross  sediment  as  seen  by  the  naked  eye  amounts  in  health 
to  nothing  more  than  a  slight  cloud,  which  settles  in  the  lower  part 
of  the  vessel  containing  the  urine.  This  cloud  is  somewhat  denser 
in  women  than  in  men,  owing  to  the  presence  of  vaginal  detritus. 
When  the  gross  sediment  amounts  to  anything  more  than  this,  it  is 
almost  invariably  made  up  of  (a)  pus,  (b)  blood,  or  (c)  urates. 
The  latter  are  dissolved  on  heating.  Pus  has  usually  its  ordinary 
yellow  color  and  general  appearance.  Blood  may  be  somewhat 

1  Except  in  some  cases  of  haemoglobinuria. 


THE  INTESTINE,   SPLEEN,    KIDNEY.  423 

lighter  or  somewhat  darker  than  under  ordinary  conditions,  but  is 
usually  recognized  without  difficulty. 

SIGNIFICANCE  OF  THKSE  SEDIMENTS. — A  urate  sediment  means 
nothing  more  than  a  concentrated  urine  standing  in  a  cold  room. 
In  the  winter-time  patients  often  bring  us,  in  great  alarm,  a  bottle 
of  milky  or  fawn-colored  and  turbid  urine,  which  is  not  in  any  way 
abnormal.  The  urates  have  been  precipitated  over  night  by  the  low 
temperature  of  the  bedroom. 

Pyuria,  or  gross  pus  in  the  urine,  is  oftenest  seen  in  cystitis 
and  less  often  in  pyelonephritis  and  renal  suppurations.  The  pus 
occurring  in  gonorrhoeal  urethritis  is  usually  much  less  in  quantity 
than  that  coming  from  the  bladder  or  kidney,  and  can  be  distin- 
guished by  the  local  signs  of  gonorrhoea.  Leucorrhoeal  pus  can  be 
excluded  by  withdrawing  the  urine  by  catheter.  The  rupture  into 
the  urinary  passages  of  an  abscess  from  the  prostate  or  any  part  of 
the  pelvis  may  produce  a  profuse  but  transient  pyuria. 

After  excluding  gonorrhoea,  leucorrhcea,  and  abscess,  which  can 
usually  be  done  with  the  help  of  a  good  history  and  a  catheter,  we 
have  left  cystitis  and  renal  suppurations,  which  it  is  very  important 
and  sometimes  difficult  to  differentiate.  In  both  we  have  the  fre- 
quent and  painful  passage  of  small  quantities  of  a  urine  which  is  in 
no  way  remarkable  except  in  containing  large  amounts  of  pus  and 
bacteria.  Cystoscopy  is  often  essential. 

In  many  cases  the  differentiation  may  be  accomplished  as  fol- 
lows :  Have  the  patient  save  for  twenty-four  hours  the  urine  voided 
at  each  passage  in  a  separate  bottle  (all  of  the  bottles  being  of  uni- 
form size),  and  mark  eaclx  bottle  with  the  hour  at  which  it  was 
tilled.  Then  arrange  the  specimens  in  a  row,  beginning  with  that 
passed  earliest  and  ending  with  that  passed  last.  Now  if  the  case 
is  one  of  cystitis  without  involvement  of  the  kidney,  the  amount  of 
pus  that  settles  is  practically  the  same  in  each  bottle  (allowing  for 
differences  in  the  amount  of  urine  in  the  different  bottles).  But  if 
the  pus  comes  from  the  kidney,  it  is  almost  always  discharged  in- 
termittently, and  hence  some  of  the  bottles  will  be  almost  free  from 
sediment,  while  in  a  group  of  the  others  the  amount  of  pus  increases 
as  we  pass  along  the  line,  reaches  a  maximum  in  one  or  two  bottles, 
and  decreases  again  in  those  representing  the  later  acts  of  micturition. 


424  PHYSICAL  DIAGNOSIS. 

Pus  from  the  bladder  is  generally  alkaline,  although  in  tubercu- 
losis it  may  be  acid;  pus  from  the  kidney  is  generally  acid.  When 
both  organs  are  involved,  as  is  frequently  the  case,  we  have  a  mixt- 
ure of  the  characteristics  of  both  types  of  pyuria,  and  cystoscopic 
examination  with  or  without  catheterization  of  the  ureters  is  usually 
necessary. 

In  renal  pyuria  we  often  have  local  signs  in  the  renal  region 
(tumor  and  tenderness ),  a  history  of  renal  colic,  and  decided  con- 
stitutional symptoms. 

In  vesical pyuria  we  have  vesical  pain,  often  tenesmus,  no  renal 
pain  or  tumor,  and  usually  slighter  constitutional  symptoms.  The 
amount  of  squanious  epithelium  (see  below)  is  sometimes  larger  in 
cystitis  than  in  renal  suppurations,  but  no  reliable  inferences  can  be 
drawn  from  the  size  or  shape  of  the  cells. 

To  determine  whether  pus  from  the  bladder  or  the  kidney  is  tu- 
berculous or  non-tuberculous  in  origin,  we  usually  inject  the  sedi- 
ment into  a  guinea-pig,  which  develops  tuberculosis  or  not  accord- 
ing to  the  nature  of  the  pus  injected.  This  method  is  much  more 
reliable  than  the  bacteriological  examination  of  the  sediment,  for 
besides  the  tubercle  bacillus  other  bacilli  which  retain  fuchsin  and 
resist  decolorization  by  strong  mineral  acid  and  by  alcohol  occasion- 
ally occur  in  the  urine. 

Hcematuria. — In  searching  for  the  source  of  the  blood  we  must 
be  sure  to  exclude  the  female  genital  organs.  Menstrual  blood  and 
uterine  bleeding  from  various  other  causes  often  contaminate  the 
urine,  and  must  be  excluded  by  using  a  catheter. 

The  causes  of  true  haematuria,  arranged  approximately  in  the 
order  of  frequency,  are : 

1.  Early  cystitis. 

2.  Stone  in  the  kidney  (less  often  vesical  stone). 

3.  Acute  nephritis  and  acute  hemorrhage  in  chronic  nephritis. 

4.  Tumors  of  the  kidney  or  bladder. 

5.  Tuberculosis  of  the  kidney  or  bladder. 

Less  common  causes  are :  floating  kidney,  hydronephrosis  and 
cystic  kidneys,  animal  parasites  in  the  urinary  passages,  poisons 
(turpentine,  carbolic  acid,  cantharides),  hemorrhagic  diseases 


THE  INTESTINE,   SPLEEN,   KIDNEY.  425 

(purpura,  scurvy,  leukaemia),  trauma  and  renal  infarction.  In 
nearly  half  of  all  cases  no  cause  can  be  found. 

In  cystitis  there  are  bladder  symptoms — pain,  tenesmus,  fre- 
quent and  painful  micturition.  The  blood  is  mixed  with  pus  and 
epithelium,  and  is  especially  abundant  in  the  urine  passed  near  the 
end  of  the  act  of  micturition.  If  the  bladder  is  irrigated  it  is  hard 
to  get  the  wash-water  clear. 

In  renal  stone  there  are  no  bladder  symptoms  to  speak  of,  the 
blood  is  pure  and  thoroughly  mixed  with  the  urine,  and  if  the  blad- 
der is  washed  out  the  final  wash-water  is  clear.  There  is  often 
renal  colic  (see  p.  419)  and  sometimes  the  passage  of  stones  or 
gravel  by  urethra. 

In  acute  nephritis  the  blood  is  rarely  fresh,  generally  dark  choc- 
olate in  color.  The  twenty-four-hour  amount  of  urine  is  small, 
and  albumin  and  casts  (see  below)  are  abundant.  General  oedema 
is  common.  Local  symptoms  in  the  kidney  or  bladder  are  absent. 

In  renal  tumor  and  especially  in  renal  tuberculosis  we  have  often 
pyuria  and  the  local  and  constitutional  evidences  above  described 
(page  418),  with  marked  and  early  bladder  symptoms  (even  when  the 
bladder  is  not  diseased). 

Tumors  of  the  bladder  need  cystoscopy  for  diagnosis. 

In  the  diagnosis  of  the  rarer  forms  of  haematuria  we  rely  chiefly 
on  the  history  (trauma,  poisons  ingested)  and  on  the  evidences 
afforded  by  cystoscopy  and  general  physical  examination. 

CHEMICAL  EXAMINATION  OF  THE  URINE. 
1.     The  Reaction  of  the  Urine. 

The  reaction  of  normal  urine  is  acid  to  litmus,  except  tempora- 
rily after  large  meals.  Its  acidity  becomes  excessive  in  fevers  or 
occasionally  without  any  known  cause. 

Alkaline  urine  has  generally  an  ammoniacal  odor  and  suggests 
cystitis.  As  a  result  of  decomposition  and  bacterial  fermentation  all 
urine  becomes  alkaline  (ammoniacal)  011  standing  exposed  to  air.1 

1  Simultaneously  a  dark-brown  color  rarely  appears:  alkaptvnuria,  a  fact 


426  PHYSICAL  DIAGNOSIS. 

Occasionally  we  find  urine  alkaline  from  fixed  alkali  and  without 
known  cause. 

The  value  of  the  litmus  test  is  chiefly  as  prim-a-facie  evidence  of 
stasis  in  the  bladder  and  cystitis.  Occasionally  tuberculous  cystitis 
and  the  first  stages  of  any  variety  of  cystitis  are  associated  with 
acid  urine,  but  in  most  cases  lasting  over  a  week  ammoniacal  fer- 
mentation and  alkalinity  appear. 

//.   Albuminuria  and  the  Tests  for  It. 

Serum  albumin  is  the  only  variety  of  clinical  importance,  and 
for  this  but  two  tests  are  necessary :  (1)  Nitric-acid  test;  (2)  test 
by  boiling. 

The  nitric-acid  test  is  best  performed  in  a  small  wineglass. 
After  filling  this  half  full  of  urine,  insert  a  small  glass  funnel  to 
the  bottom  of  the  urine  and  gently  pour  in  concentrated  nitric  acid. 
If  albumin  is  present,  a  white  ring  forms  at  the  junction  of  the  acid 
with  the  urine,  either  immediately  or  in  the  course  of  ten  minutes. 
If  carefully  performed  this  test  is  delicate  enough  for  all  clinical 
purposes,  but  since  some  of  the  albumoses  give  a  similar  precipitate, 
the  boiling  test  should  be  used  as  a  control  whenever  a  positive  re- 
action is  obtained  with  nitric  acid.  None  of  the  other  rings,  ob- 
servable above  or  below  but  not  at  the  junction  of  the  acid  with  the 
urine,  is  of  any  clinical  importance. 

The  Boiling  Test. — To  half  a  test  tube  full  of  urine  add  three  or 
four  drops  of  dilute  acetic  acid,  and  boil  the  upper  three-quarter 
inch  of  the  urine.  If  albumin  is  present  a  white  cloud  appears.  If 
albumose  is  present  a  white  cloud  appears  on  heating,  disappears  on 
boiling,  and  reappears  on  cooling.  In  performing  this  test  the  ad- 
dition of  acetic  acid  as  above  described  is  absolutely  necessary  to 
prevent  error. 

For  the  detection  of  albumin  no  other  tests  are  needed.  For  its 
approximate  quantitative  estimation,  Esbach's  method  is  the  best. 

Esbach's  Method. — A  special  tube  (see  Fig.  190)  is  employed. 

at  present  of  no  clinical  significance  except  that  such  urines  reduce  Fehling':.. 
solution  and  may  be  mistakenly  supposed  to  contain  sugar. 


THE  INTESTINE,   SPLEEN,    KIDNEY. 


427 


Urine  is  poured  iii  up  to  the  mark  "U,"  and  then  Esbach's  reagent ' 

up  to  the  mark  "R."-_  The  tube  is  then  corked,  inverted  about  half 

a  dozen  times,  and  set  aside  for  twenty-four  hours.     A  precipitate 

falls  and  the  amount  per  mille  is  then  read  off  on 

the  scale  etched  upon  the  tube.     If  the  urine  is  not 

acid  it  must  be  made  so  with  dilute  acetic  acid,  and 

unless  its  specific  gravity  is  already  very  low  it  should 

be  diluted  once  or  twice  with  water  so  as  to  bring 

the  gravity  below  1.008.     After  such  a  dilution  we 

must,  of  course,  multiply  the  result  obtained  by  a 

figure  corresponding  to  the  dilution.      The  method 

is  not  accurate,  but  is  probably  accurate  enough  for 

practical  purposes. 


III.    Significance  of  Albuminuria. 

It  is  important  to  realize  that  albuminuria  very 
often  occurs  without  nephritis  and  that  nephritis  oc- 
casionally occurs  without  albuminuria.  Among  the 
more  important  types  not  due  to  kidney  disease  are 
the  following :  (1)  Febrile  albuminuria;  (2)  albumi- 
nuria from  renal  stasis;  (3)  albuminuria  due  to  pus, 
blood,  bile,  or  sugar  in  the  urine;  (4)  toxic  albuminuria. 

Besides  these,  there  are  a  good  many  cases  of 
albuminuria  occurring  in  diseases  of  the  blood,  after 
violent  exertion,  after  epileptic  attacks,  and  without 
any  known  cause.  Many  of  the  latter  group  occur 
only  in  the  daytime  when  the  patient  is  in  an  upright 
position,  and  are  absent  as  long  as  the  patient  lies 

down   (orthostatic  albuminuria)-.    others  occur  inter-    FlG-  i'->o.  — Es- 
...       \  ,.  ,        .    ,  ,      ,        ,.         bach's    Albu- 

mittently  and  sometimes  at  regular  intervals  (cyclic      menometer. 
albuminuria) . 

Exclude  fever,  circulatory  disturbance,  anaemia,  poisons — such 
as  cantharides,  turpentine,  carbolic  acid,  and  arsenic    -and  deposits 

1  Esbach's  reagent :  Picric  acid,  10  gm. ;  ci trie  acid,  20  gin. ;  distilled  water, 
l.OOOc.c. 


428  PHYSICAL  DIAGNOSIS. 

of  blood  or  pus  in  the  urine,  before  deciding  that  a  case  of  albumi- 
nuria  is  due  to  nephritis.  To  exclude  the  cyclic  and  orthostatic 
varieties  is  more  difficult,  and  some  authorities  believe  that  these 
represent  true  nephritis  in  a  more  or  less  latent  stage.  In  general, 
however,  it  is  a  good  rule  not  to  attribute  albuminuria  to  nephritis 
unless  there  is  other  and  more  convincing  evidence  in  the  physical 
characteristics  of  the  urine  and  in  the  other  organs  of  the  patient. 
If  the  24- hour  amount  and  the  gravity  are  approximately  normal, 
and  if  there  is  no  oedema,  no  increased  blood  pressure,  no  cardiac 
hypertrophy,  no  uraemic  manifestations,  and  nothing  alarming  in  the 
sediment  of  the  urine,  we  should  not  diagnose  nephritis.  I  shall 
discuss  this  point  further  in  the  section  on  the  examination  of  the 
sediment  (see  page  431).  It  will  be  noted  that  practically  all  the 
types  of  albuminuria  not  due  to  nephritis  are  transient,  while,  with 
the  exception  of  certain  stages  of  chronic  interstitial  nephritis,  the 
albuminuria  of  nephritis  is  as  permanent  as  the  nephritis  itself. 

IV.    Glucosuria  and  Its  Significance. 

For  glucose  in  the  urine  we  need  but  one  qualitative  and  one 
quantitative  test,  viz.,  Fehling's  test  and  the  fermentation  test. 

1.  Fehling's  Test. — Mix  in  a  test  tube  equal  parts  of  a  standard 
solution  of  copper  sulphate  '  and  a  standard  solution  of  alkaline  tar- 
tartes,"  and  add  to  this  mixture  an  equal  amount  of  urine.  Mix 
and  heat  nearly  to  boiling.  The  amount  of  error  entailed  by  boil- 
ing is  slight  and  unimportant,  but  the  only  advantage  of  boiling  is 
a  slight  saving  of  time.  If  sugar  is  present  a  yellow  or  reddish- 
yellow  precipitate  occurs,  either  at  once  or  (if  the  amount  of  sugar 
is  very  small)  after  the  urine  has  cooled.  Fehling's  solution  may 
also  be  used  for  quantitative  estimation  of  sugar,  but  it  is  more 
convenient  to  use : 

1  Made  by  dissolving  84.64  gm.  pure  CuSO4  in  water  and  then  adding 
enough  water  to  make  500  c.c. 

2  Made  by  dissolving  173  gm.  Rochelle  salts  and  60  gm.  sodic  hydrate  each 
in  200  c.c.  of  water,  mixing  the  two  solutions,  and  adding  water  to  make 
500  c.c. 


THE  INTESTINE,    SPLEEN,    KIDNEY.  429 

2.  The  Fermentation  Test. — Take  the  specific  gravity  of  the 
urine  as  carefully  as  possible.  Pour  six  or  eight  ounces  of  urine 
into  a  wide-mouthed  vessel  and  crumb  into  it  half  a  cake  of  fresh 
Fleischmann's  yeast.  Set  the  flask  aside  in  a  warm  place,  and  after 
twenty-four  hours  test  the  supernatant  fluid  with  Fehling's  solution 
as  above;  if  sugar  is  still  present  fermentation  must  be  allowed  to 
go  on  twenty-four  hours  longer.  As  soon  as  a  negative  reaction  to 
Fehling's  has  been  secured  (whether  in  twenty-four  or  forty-eight 
hours),  the  specific  gravity  of  the  filtered  urine  is  again  taken.1  It 
will  be  found  lower  than  before  the  fermentation,  and  for  every 
degree  of  specific  gravity  lost  we  may  reckon  that  0. 23  per  cent  of 
sugar  has  been  fermented  out  of  the  urine.  Thus  if  the  reading 
was  1.0-40  before  fermentation  and  1.020  afterward,  we  multiply 
the  difference  between  these  readings,  20,  by  0.23,  giving  4.6  per 
cent — the  percentage  of  sugar. 

Fehling's  test  should  be  applied  to  every  urine  examined  ;  it  takes 
but  a  minute  or  two.  When  it  shows  a  yellow  or  red  precipitate,  the 
fermentation  test  should  also  be  tried  ;  and  if  both  tests  are  positive 
we  shall  run  but  a  negligible  risk  in  saying  that  glucose  is  present. 
From  the  result  of  the  fermentation  test  and  the  twenty-four-hour 
amount  of  urine,  we  can  estimate  the  daily  output  of  sugar  through 
the  urine. 

Permanent  glucosuria  means  diabetes  mellitus.  Transitory  glu- 
cosuria  may  be  due  to  a  great  many  causes,  among  which  are :  (1) 
Diseases  of  the  liver;  (2)  diseases  of  the  brain,  organic  or  func- 
tional, especially  the  latter;  (3)  infectious  fevers;  (4)  poisons,  es- 
pecially narcotics  (alcohol,  chloral,  morphine)  ;  (5)  pregnancy;  (6) 
exophthalmic  goitre. 

Experimental  ("  alimentary ")  glucosuria  can  be  produced  in 
many  of  these  same  diseases  by  giving  the  patient  100  gm.  of  glu- 
cose in  solution. 

The  differential  diagnosis  of  the  cause  of  glucosuria  depends  on 
the  recognition  of  one  of  the  above  conditions. 

1  The  room  temperature  must  be  approximately  the  same  as  at  the  time 
of  the  previous  reading. 


430  PHYSICAL   DIAGNOSIS. 

V.    The  Acetone  Bodies. 
Acetone,  Diacetic  and  Beta-Oxybutyric  Acids. 

1.  Test  for  Acetone. — To  about  one-sixth  of  a  test  tube  of  urine 
add  a  crystal  of  sodium  nitroprusside,  and  then  NaOH  to  strong 
alkalinity.     Shake  and  add  to  the  foam  a  few  drops  of  glacial  acetic 
acid.     A  purple  color  shows  acetone. 

2.  Test  for  Diacetic  Acid. — A  Burgundy  red  color  when  a  strong 
aqueous  solution  of  ferric  chloride  is  added  to  fresh  urine  (not  pre- 
viously boiled)  in  a  test  tube.     If  this  reaction  is  well  marked  beta- 
oxybutyric  acid  is  probably  also  present,  but  we  possess  no  clinical 
test  for  the  latter  substance. 

Significance  of  the  Acetone  Bodies. — Diminished  utilization  of 
carbohydrate  food  by  the  body  is  usually  the  cause  of  the  appear- 
ance of  these  bodies  in  the  urine.  This  may  occur :  (a)  Because  suf- 
ficient carbohydrates  are  not  eaten  (starvation,  rectal  alimentation, 
fevers,  etc.).  (i)  Because  they  are  not  absorbed  (vomiting,  diar- 
rhoea, etc.).  (c)  Because  they  are  not  assimilated  (diabetes). 

VI.    Other  Chemical  Tests. 

The  information  to  be  derived  from  testing  for  indican,  for  the 
amounts  of  urea,  uric  acid,  chlorides,  phosphates,  and  sulphates, 
does  not  seem  to  me  sufficient  to  justify  the  time  spent.  The  same 
is  true  of  the  diazo  reaction. 

Simon's  lucid  arguments  for  the  value  of  the  indican  test  have 
not  been  borne  out  by  my  experience  with  it  in  diagnostic  puzzles. 
The  tests  for  urea  and  uric  acid  are  of  value  only  when  we  possess 
a  knowledge  of  all  the  factors  governing  their  excretion,  knowledge 
which  in  clinical  work  we  almost  never  have.  Diminution  or  ab- 
sence of  the  urinary  chlorides  in  pneumonia  is  not  constant,  and 
occurs  in  many  other  infections  (typhoid,  scarlet  fever,  etc.).  The 
diazo  reaction  is  nearly  constant  in  typhoid,  but  is  occasionally 
found  in  so  many  other  febrile  and  cachectic  states  that  most  clini- 


THE  INTESTINE,    SPLEEN,    KIDNEY.  431 

cians  have  ceased  to  rely  on  it.  Its  value  in  the  prognosis  of 
phthisis  is  slight.  I  believe  that  the  general  abandonment  of  the 
tests  for  the  sulphates  and  phosphates  will  soon  be  followed  by  the 
abandonment  of  the  tests  for  urea,  uric  acid,  indican,  and  the  chlo- 
rides. The  use  of  these  tests  gives  the  appearance  of  accuracy  and 
scientific  method  in  diagnosis — the  appearance,  but  not  the  reality. 

VII.   Microscopic  Examination  of  Urinary  Sediments. 

Methods. — A  centrifuge  is  convenient,  but  not  necessary.     The 
sediment  should  be  allowed  to  settle  in  a  conical  glass  (see  Fig. 
191),  whence  a  drop  of  it  can  be  transferred  to  a  slide  by  means  of 
a  pointed  glass  pipette.     Close  the  upper  end  of  this 
with  the  forefinger  and  introduce  the  pointed  end  into 
the  densest  portion  of  the  sediment ;  next  very  slightly 
relax  the  pressure  of  the  forefinger  until    urine   and 
sediment  flow  into  the  lower  one-half  or  three-fourths 
inch  of  the  pipette.     Then  resume  firm  pressure  with 
the  forefinger,  withdraw  the  pipette,  wipe  the  outside 
of  it  dry,  put  its  point  upon  a  microscopic  slide,  and   FIG.  191.— con- 
again  stiyhtfy  relax  the  pressure  of  the  forefinger  so      lcal  Glass  '°r 
as  to  let  a  small  drop  of  urine  and  sediment  run  out     ments. 
upon  the  slide.     Cover  this  drop  with  a  seven-eighths 
inch  cover  glass,  and  examine  it  with  a  Leitz  objective  No.  5  or 
Zeiss  DD. 

The  arrangement  of  the  light  is  most  important.  The  iris  dia- 
phragm should  be  closed  until  one  can  just  distinguish  the  outlines 
of  the  cells  and  other  objects  in  the  field.  If  more  light  is  ad- 
mitted the  pure  hyaline  casts  will  be  invisible. 

Results. — The  objects  of  chief  importance  in  the  sediment  are: 
(a)  Casts;  (&)  cells;  (c)  crystals;  (d)  animal  parasites  or  their 
eggs. 

1.  Casts. — Casts,  or  moulds  of  the  renal  tubules,  may  be  homo- 
geneous and  transparent  (hyaline,  Fig.  192,  1*)  or  may  have  attached 
to  this  matrix  a  variety  of  granules,  cells,  crystals,  or  fat  drops. 
According  to  the  variety  of  passengers  carried  down  from  the  kid- 


432 


PHYSICAL  DIAGNOSIS. 


FIG.  192.-  Casts.    1,  Hyaline  casts:  2  and  3,  hyaline  casts 
with  cells  and  blood  adherent;  4,  "  cylindroids." 


ney  on  the  casts,  we  call  them  granular,  brown-granular,  cellular^ 

blood,  fatty,  or  crystal- 
bearing  casts  (see  Fig. 

192,  8  and  3,  and  Fig. 

193,  1,2,  3,  and  4). 
Dense  or  highly  re- 

fractile  casts,  colorless 
or  straw  colored,  are 
occasionally  seen,  and 
•  are  often  given  a  va- 
riety of  names  quite 
unjustified  by  any 
knowledge  of  their 
composition  (e.g., 

"  waxy,"  *  "  fibrinous," 
g^  -\ 

From     strands    of 

mucus,  foreign  bodies,  and  other  sources  of  error,  true  casts  may 
be  distinguished  by  the  fol- 
lowing traits  : 

(a)  Their  sides  are  par- 
allel. ' 

(£)  One  end  is  rounded  ; 
sometimes  both  ends. 

Red  corpuscles  and  other 
celh  upon  casts  are  to  be  rec- 
ognized —  the  former  by  the 
size,  shape,  and,  if  fresh,  by 
their  color  (pale  straw)  j  the 
latter  by  the  presence  of  a 
nucleus. 

Fat   drops  are  spherical 

FIG.  193.  —  Casts.     1,  Blood-casts;  2,  fatty  casts;  3, 

1  Some  dense,  refractile  casts  granular  casts  ;  A,  cellular  casts. 

give  the  amyloid  reaction,  but 

this  does  not  indicate  amyloid  kidneys  and  has  no  known  clinical  signifi 
cance. 


THE  INTESTINE,   SPLEEN,    KIDNEY.  433 

and  very  highly  refractile,  so  that  they  seem  to  have  a  black  line 
at  their  periphery. 

Crystals  can  be  recognized  by  their  angles.  They  are  of  no  im- 
portance. 

Other  bodies  on  casts  are  called  granules. 

SIGNIFICANCE  OF  CASTS. — Casts  may  occur  in  health  (unless  we 
choose  to  class  muscular  fatigue  &s  disease)  as  well  as  under  any  of 
the  conditions  giving  rise  to  albuminuria  (see  page  427).  They  are 
usually  more  numerous  in  nephritis  than  in  most  other  conditions. 
-Any  type  of  cast  may  occur  in  any  type  of  nephritis,  but 

Cellular,1  blood,  and  brown-granular  casts  are  most  often  found 
in  acute  nephritis. 

Fatty,  highly  refracting,  or  dense  casts  most  often  predominate 
in  chronic  glomerular  nephritis  ("  diffuse  "  or  "  parenchymatous  " 
nephritis). 

Hyaline  and  granular  casts  may  occur  in  any  type  of  nephritis 
and  in  many  other  conditions  (fatigue,  renal  stasis,  etc.).  In  the 
urine  of  persons  over  fifty  years  of  age  the  presence  of  a  few  hya- 
line and  granular  casts  has  no  known  clinical  significance,  and  may 
probably  be  considered  physiological. 

Periods  occur  in  the  course  of  many  cases  of  chronic  interstitial 
nephritis  when  no  casts  can  be  found.  If  any  occur  they  are  usually 
of  the  hyaline  and  fine  granular  types. 

2.  Free  Cells  in  Urinary  Sediment.  A.  Recognition.  — The  pres- 
ence of  macroscopic  pus  or  blood  already  alluded  to  may  be  veri- 
fied by  the  microscope. 

(a)  Fresh  red  cells,  lately  freed  from  the  blood-vessels,  preserve 
their  straw-yellow  color.     Their  presence  points  to  the  recent  effu- 
sion of  blood,  probably  from  the  bladder,  urethra,  or  renal  pelvis. 

(b)  Abnormal  blood,  decolorized  and  shadowy  red  discs,  can  be 
recognized  with  practice  by  their  size  and  shape.     We  may  infer 
that  they  have  remained  some  time  in  the  urine  and  have  probably 
come  from  the  kidney. 

1  "Cellular  "  is  a  better  term  than  "epithelial,"  since  we  have  no  marks  for 
recognizing  renal  epithelium  or  for  distinguishing  a  renal  cell  from  a  lym- 
phocyte. 

28 


434 


PHYSICAL  DIAGNOSIS. 


(c)  Pus  is  easily  recognized  as  a  rule  by  the  presence  of  the 
familiar  polymorphous  nucleus  in  most  of  the  cells.     Should  doubt 
arise,  a  drop  of  dilute  acetic  acid  allowed  to  run 

under  the  cover  glass  will  sharpen  the  outlines 
of  the  nuclei  and  facilitate  their  recognition. 

(d)  Spermatozoa  (see  Fig.  194)  are  often  seen 
in  the  urine  after  coitus  or  noctuAal  emissions. 
They  are    of   no   importance,   except  that  when 
appearing  in  the  urine  of  females  they  may  afford 
valuable  medico-legal  evidence.     They  are  easily 

recognized  by  their  size  and  shape.  FIG.  194.— spermatozoa. 

(e)  Other  varieties  of  cells  need  not  be  differ- 
entiated, since  almost  any  of  the  varieties  usually  described  (squa- 
mous,  spindle-shaped,  caudate,  etc. )  may  come  from  any  part  of  the 
urinary  tract.       Renal  cells  are   not  recognizable   by  our  present 

methods  of  examination. 

Any  of  the  urinary  cells 
may  contain  fat  drops,  but  these 
have  no  special  diagnostic  sig- 
nificance. 

B.  Interpretation.  — 'The 
significance  of  large  quantities 
of  blood  or  of  pus  in  the  urine 
has  already  been  discussed 
(page  423).  When  recognizable 
only  by  the  microscope  they 
have  no  diagnostic  value. 

The  presence  of  large  num- 
bers of  cells  not  coming  from 
the  blood-vessels  (squanious, 
spindle-shaped,  etc.)  is  usually 
associated  with  cystitis,  pro- 
vided the  accidental  admixture 

of  vaginal  detritus  is  excluded.  Pyelitis  and  renal  suppurations 
may  fill  the  sediment  with  similar  cells,  and  only  by  other  methods 
of  examination  (cystoscopy,  ureteral  catheterization)  and  by  tak- 


FIG.  195.— Crystals  of  Triple  Phosphate  (prisms) 
and  Ammonium  Urate  (small  spheres  with 
spines) . 


THE  INTESTINE,    SPLEEN,    KIDNEY. 


435 


ing  account  of  all  the  facts  in  the  case  can  the  differentiation  be 
made. 

3.    Crystals  in  Urinary  Sediments  (see  Figs.  195,  196,  and  197). 

—The  varieties  oftenest  seen 
are:  (a)  Triple  phosphate 
(ammoniacal  urine,  cystitis) ; 
(b)  ammonium  urate  ;  (c) 
uric 
.  _  ate. 

'P  &      ^  »  -t,  "*    o  _ 

J 

"fe^7^ 
ffe\ 

*  *    lU- 


acid;    (d)   calcic   oxal- 


FIG.  196.-  Crystals  of  Uric  Acid  (whetstone-shaped) 
with  Calcic  Oxalate  (small  octahedral)  and  Amor- 
phous Urates. 


All  of  these  varieties  are 
colorless  except  the  uric-acid 
crystals,  which  are  usually 
light  or  dark  yellow  or  yel- 
lowish-brown. 

None  of  these  have  much 
significance  in  diagnosis. 
The  first  two  merely  confirm 
the  evidence  of  urinary  de- 
composition (usually  from 
cystitis)  afforded  by  the  re- 
action, turbidity,  and  odor  of  the  urine. 

Uric-acid  crystals,  if  present  in  great  numbers  in  the  urine  when 
passed,  suggest  the  search  for 
macroscopic  masses  (gravel) 
and  for  other  evidence  of  renal 
stone,  but  as  a  rule  they  are  of 
no  importance. 

The  same  may  be  said  of 
calcium  oxalate.  Oxaluria  is 
one  of  the  most  persistent  bug- 
bears of  the  medical  profes- 
sion, but  it  is  utterly  harmless 
except  in  the  rare  cases  in  which 
it  accompanies  macroscopic 
gravel  and  points  to  renal  stone. 

4.  Animal  parasites  or  their  eggs  are  occasionally  found  in  the 


FIG.  197.— Calcic  Oxalate  Crystals. 


436 


PHYSICAL  DIAGNOSIS. 


urine,  with  or  without  haematuria  and  evidence  of  cystitis  (see  Figs. 
198  and  199). 


m 


M 


\ 

vv 


Fio.  198.— Vinegar  Eels  in  Urine.  (Billings.)  a.  Protruded  hooks  of  male;  7>,  top-shaped 
oesophageal  enlargement.  The  Strongyloidts  stercoralis  (see  above,  Fig.  187,  page  410) 
has  also  been  found  in  the  urine. 


Summary  of  the  Urinary  Pictures  Most  Useful  in  Diagnosis.    . 

Aside  from  polyuria,  oliguria,  hcematuria,  and  pyuria,  which 
have  already  been  discussed,  the  most  important  conditions  in 
which  the  urine  gives  valuable  diagnostic  evidence  are : 


THE  INTESTINE,    SPLEEN,   KIDNEY. 


437 


1.  Cystitis. — Urine  passed  frequently,  painfully,  and  in  small 
amounts.  Turbid,  ammoniacal,  and  offensive  (after  the  earliest 
stages).  Much  pus  and  many  other  cells  are  found  in  the  sedi- 


FIG.  199.— Bilharzia  Eggs  in  the  Urine,  with  Blood,  Calcic  Oxalate,  and  a  Hyaline  Cast.    (O'Neil.) 


ment,   with  bacteria,   triple    phosphate    crystals,    and  amorphous 
debris. 

2.  Acute  Nephritis  (or  acute  exacerbations  in  chronic  cases). — 
Scanty,  heavy,  highly  albuminous  urine,  often  bloody  and  contain- 
ing in  the  sediment  much  blood  and  many  cells,  free  or  on  casts. 
Other  varieties  of  casts  occur,  but  are  not  characteristic.     In  con- 
valescence the  urine  becomes  abundant  and  of  light  weight,  and 
the  other  abnormalities  gradually  disappear. 

3.  Chronic    Glomerular   Nephritis  ("  parenchymatous  "). — The 
urine  is  rather  scanty,  pale,  and  of  light  weight  (1.012-1.018,)  with 
a  large  amount  of  albumin  and,  in  the  sediment,  much  fat — free, 


438  PHYSICAL  DIAGNOSIS. 

in  cells,  and  on  casts.  Also  found,  but  not  characteristic,  are  all 
the  other  varieties  of  casts.  If  death  does  not  ensue  within  eigh- 
teen months,  the  urine  is  apt  to  assume  the  characteristics  of  the : 

4.  Contracted  kidney  (primary,  secondary,  or  arterio-sclerotic), 
with  polyuria  (often  several  quarts;  urine  especially  abundant  at 
night),  low  specific  gravity  (1.010  or  less).     Traces  of  albumin  and 
a  few  hyaline  and  granular  casts  occur  steadily  or  intermittently. 

5.  Pyelitis  and  acute  hcematogenous  renal  suppurations  are  dis- 
eases much  more  commonly  recognized  since  1904  than  previously. 
The  presence  of  bacteria  (usually  colon  bacilli)  and  pus  without  many 
cells  of  other  types  in  acid  urine  should  always  lead  to  bacteriologi- 
cal and  cystoscopic  examinations.     The  presence  of  pain,  tenderness, 
or  tumor  in  the  region  of  the  kidney  (usually  the  right  kidney)  and 
the  occurrence  of  fever  and  leucocytosis  support  the  diagnosis,  espe- 
cially in  children  and  in  women  near  parturition.     To  distinguish 
pure  pyelitis  from  pyeiitis  complicating  a  renal  infection  is  at  present 
very  difficult. 


CHAPTER  XXL 

THE   BLADDER,    RECTUM,    AND    GENITAL    ORGANS. 
THE  BLADDER. 

Incidence  of  Bladder  Disease. 

(Massachusetts  General  Hospital,  1870-1905.) 

Cystitis 829  cases. 

Stone 538    " 

Cancer 57     « 

Papilloma 20    " 

Tuberculosis 43    " 

Data. 

Distention,  tumor,  the  urine,  and  the  results  obtained  by  cystos- 
copy,  by  catheter  ization,  by  rectal  and  vaginal  examination,  by  the 
x-ray,  and  by  sounding  for  stone  furnish  most  of  our  direct  evidence 
in  bladder  disease.  Pain  in  the  bladder  or  near  the  end  of  the  penis, 
and  frequent,  painful  micturition  with  vesical  tenesmus  or  strain- 
ing, are  common  symptoms  in  various  lesions  of  the  organ,  and 
direct  our  attention  to  it,  though  they  do  not  indicate  the  nature  of 
the  trouble. 

/.   Distention  of  the  Bladder. 

In  both  sexes,  distention  is  often  wholly  unknown  to  the  patient, 
and  may  be  accompanied  by  frequent  acts  of  urination,  especially 
in  prostatic  obstruction.  A  distended  bladder  is  readily  recognized 
by  palpation  as  a  smooth,  round,  firm,  symmetrical  tumor  in  the 
median  line,  above  the  pubes.  The  tumor  is  dull  on  percussion,  and 
in  slight  degrees  of  distention  this  dulness  above  the  pubes  may  be 
the  only  physical  sign  obtainable.  In  well-marked  cases,  which  are 
most  common  in  males,  the  distended  bladder  may  reach  to  the 
navel  or  even  above  it,  and  the  beginner  is  usually  astonished  at  its 


440 


PHYSICAL  DIAGNOSIS. 


dimensions  and  its  firm,  resistant  surface  (see  Fig.  200).  Diagnosis 
rests  on  the  infrequency  of  other  tumors  of  this  region  in  men  and 
on  the  result  of  catheterization  or  suprapubic  aspiration.  In  females 
a  history  of  failure  to  pass  urine  almost  invariably  makes  the  diag- 
nosis obvious,  though  occasionally  after  operations  distention  of  the 
bladder  and  dribbling  of  urine  may  go  together  in  women,  as  they 
so  frequently  do  in  men. 

The  commonest  causes  of  distended  bladder  are : 

(1)  Prostatic  hypertrophy,  alone  or  combined  with 

(2)  Old  strictures  of  the  urethra. 
Less  common  are : 

(3)  Spasm  of  the  urethra  in  gonorrhoea. 

(4)  Acute  prostatitis. 

(5)  Paralysis  of  the  bladder,  from  disease  or  injury,  after  opera- 
tion, and  in  fevers. 

(6)  Tumor  or  stone  near  the  neck  of  the  bladder. 

The  diagnosis  of  the  cause  of  distention  rests  on  the  history,  the 

result  of  attempts  at  catheteriza- 
tion, the  rectal  examination,  the 
condition  of  the  urine,  and  the  phy- 
sical signs  in  other  parts  of  the 
body.  A  long  history  of  frequent 
micturition,  especially  at  night,  in 
an  old  man,  an  obvious  enlarge- 
ment of  the  prostate  felt  by  rectum, 
and  the  passage  of  ammoniacal 
urine  suggest  prostatic  obstruction. 
The  information  obtained  during 
the  passage  of  a  catheter  usually 
clinches  the  diagnosis. 

Acute  retention,  with  no  previous 

history  of  frequent  micturition  or  foul-smelling  urine  in  a  young  or 
middle-aged  man,  who  has  had  gonorrhoea  and  may  or  may  not 
have  noticed  a  diminution  in  the  size  of  the  stream  of  urine  passed, 
suggests  a  urethral  stricture.  The  catheter  decides. 

Spasm  of  the  urethra  may  occur  in  acute  gonorrhoea,  and  pro- 


FIG.  200.— Distended  Bladder  Reaching 
Above  the  Navel. 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS.   441 

duces  a  retention  which  may  often  be  overcome  by  hot  poultices  and 
enemata.  The  history  and  the  effects  of  treatment  suggest  the 
cause  of  the  retention. 

Acute  prostatitis,  as  a  cause  of  retention  following  gonorrhoea, 
is  suggested  by  pain  and  tenderness  in  the  perineum,  painful  defe- 
cation, fever,  perhaps  chills,  and  a  hot,  tender  prostate  felt  by  rec- 
tum. Abscess  may  form  and  discharge  by  urethra  or  rectum. 

Paralysis  of  the  bladder,  as  a  cause  of  retention,  is  usually  obvi- 
ous from  the  history  and  from  the  evidence  of  disease  of  the  spinal 
cord,  or  of  operation  and  semicomatose  states  (as  in  fevers  and 
shock). 

Tumors  of  the  bladder  are  suggested  by  intermittent  hsematuria 
with  vesical  irritation,  and  confirmed  by  cystoscopic  examination. 

II.    The  Urine  as  Evidence  of  Bladder  Disease. 

This  has  been  described  above  (page  437).  Cystitis,  acute  or 
chronic,  usually  gives  characteristic  evidence  of  itself  in  the  urine, 
and  suggests  thereby  the  possibility  of  gonorrhoea,  of  vesical  stone, 
of  prostatic  or  other  obstruction  to  the  outflow,  and  of  vesical  tu- 
berculosis. When  a  urine  like  that  of  chronic  interstitial  nephritis 
occurs  with  chronic  prostatic  obstruction,  the  relief  of  the  obstruc- 
tion is  necessary  if  we  are  to  prevent  progressive  development  of 
cirrhotic  kidney  from  back  pressure. 

Frequent  micturition  is  much  commoner  and  less  significant  in 
women  than  in  men.  All  sorts  of  "  nervousness  "  and  emotional 
strain  produce  this  symptom  in  women,  independent  of  any  demon- 
strable source  of  irritation  in  the  urinary  tract.  Aside  from  these 
conditions  the  symptom  is  oftenest  met  with  in : 

(a)  Cystitis,  with  characteristic  changes  in  the  urine. 

(b*)  Prostatic  obstruction,  with  evidence  of  retention. 

(c)  Gonorrhoea,  with  evidence  of  this  disease. 

(<T)  Paralysis  of  the  bladder  (see  above). 

(«)  Over  concentration  of  the  urine  (estimated  by  the  color  and 
specific  gravity). 

III.   Stone  in  the  Bladder. — Pain  near  the  end  of  the  penis,  espe- 


442  PHYSICAL   DIAGNOSIS. 

cially  at  the  end  of  micturition  and  aggravated  by  jolting  or  active 
motion,  frequent  urination,  especially  in  the  daytime,  sudden  inter- 
ruption of  the  stream  of  Urine,  and  haematuria  at  the  end  of  micturi- 
tion, are  the  most  frequent  symptoms  of  stone,  especially  if  they 
occur  in  boys.  In  old  men  stone  may  be  wholly  without  character- 
istic symptoms,  and  at  any  age  the  symptoms  can  never  do  more 
than  suggest  the  possibility  of  stone  and  the  advisability  of  search- 
ing for  it  systematically  with  a  proper  sound. 

IV.  Tiiberculosis  of  the  ^Bladder. — Cystoscopy  and  the  recogni- 
tion of  tubercle  bacilli  by  animal  inoculation  are  the  only  reliable 
means  of  diagnosis.  A  chronic  cystitis  in  a  young  or  middle-aged 
person,  especially  with  an  acid  urine,  is  suggestive. 


THE  RECTUM. 

It  is  not  and  should  not  be  a  part  of  routine  physical  examina- 
tion to  examine  the  rectum.  The  commonest  conditions  which  call 
for  such  investigation  are : 

(a)  Hemorrhage  at  stool. 

(£)  The  protrusion  after  defecation  of  something  which  is  not 
easily  returned  ("piles  "). 

(c)  Painful  defecation  or  pain  in  the  region  of  the  rectum  at 
other  times. 

(rf)  The  presence  of  an  ulcer  or  sinus  near  the  rectum. 

(e~)  Habitual  constipation,  not  explained  by  lesions  elsewhere. 

(/)  Intestinal  obstruction. 

(g)  All  subacute  diarrhoeas  of  elderly  persons  (cancer). 

(h)  Suspected  appendicitis,  prostatitis,  prostatic  tumor  or  ob- 
struction, or  diseases  of  the  seminal  vesicles. 

(i)  Pelvic  symptoms  in  women  with  tight  hymen. 

The  diseases  of  the  rectum  which  we  are  especially  on  the  look- 
out for  are:  (1)  Hemorrhoids;  (2)  fissure  of  the  anus;  (3)  ischio- 
rectal  abscess;  (4)  fistula  in  ano;  (5)  cancer  of  the  rectum.  Less 
common  are:  (6)  pruritus  ani;  (7)  prolapse  of  the  rectum;  (8) 
ulceration  or  stricture  of  the  rectum. 


THE  BLADDER,   RECTUM,  AND  GENITAL  ORGANS.       443 


Methods. 

For  most  examinations  the  finger  suffices.  It  should  be  covered 
by  a  thin,  rubber  finger-cot,  greased  with  vaseline,  and  should  be 
introduced  slowly  and  gently  while  the  patient  strains  down  as  dur- 
ing defecation. 

The  examining  finger  should  note  the  presence  of  abnormal 
prominences  or  resistance  (piles,  tumors)  in  any  part  of  the  rectum, 
of  tender  spots  (ulcer,  abscess),  and  strictures.  The  shape  and  size 
of  the  prostate  gland,  its  consistence,  and  the  presence  or  absence 
of  tenderness  in  it  are  of  importance.  The  normal  seminal  vesicles 
can  be  felt  if  distended.  If  they  are  hard  and  nodular,  tuberculosis 
should  be  suspected. 

High  up  on  the  right  side  the  finger  may  touch  a  tender  spot  if 
an  inflamed  appendix  is  near  the  pelvic  brim. 

In  women  the  uterus,  especially  if  retroverted,  may  be  easily 
felt,  and  most  of  the  other  details  of  pelvic  examination  (see  below, 
page  449)  can  be  more  or  less  clearly  made  out. 

For  higher  and  more  thorough  examination  a  cylindrical  specu- 
lum and  a  head  mirror  should  be  used,  with  the  patient  in  the 
knee-chest  position. 

Hemorrhoids. — The  diagnosis  of  external  hemorrhoids,  which 
can  easily  be  brought  outside  the  anus,  is  made  at  a  glance.  Inter- 
nal hemorrhoids  are  best  seen  with  a  rectal  speculum,  and  may  re- 
semble the  external  or  may  consist  of  "bright  red,  spongy,  granular 
tumors,  rarely  larger  than  a  ten-cent  piece,  and  situated  high  up  in 
the  rectum  "  (iicevoid  piles) . 

Fissure  of  the  amis  is  often  connected  with  a  small  ulcer  and 
with  oedematous  folds,  which  resemble  an  external  pile  but  are 
much  more  tender.  On  separating  these  folds  the  fissure  comes  into 
sight.  It  produces  severe  pain  during  and  after  defecation. 

Ischio-rectal  abscess  presents  near  the  anus  the  ordinary  signs  of 
abscess  with  pain  radiating  through  the  pelvis,  but  may  open  either 
within  or  outside  the  rectum  and  results  in 

Fistula    in    ano,    a    sinus    beside    the    rectum,     opening    in- 


444  PHYSICAL  DIAGNOSIS. 

ternally,  externally,  or  in  both  directions.  It  may  be  very  tortuous 
and  need  examination  with  speculum  and  probe.  Tuberculosis  is 
always  to  be  suspected  in  such  fistulas. 

Cancer  of  the  rectum  is  suggested  by  the  occurrence  of  recta? 
pain  during  defecation,  with  blood  in  the  stools  and  alternating 
diarrhoea  and  constipation,  usually  with  some  pallor  and  emacia- 
tion, in  persons  past  middle  life.  Owing  to  neglect  of  a  thorough 
examination  many  cases  are  at  first  mistaken  for  piles. 

The  examining  linger  reaches  a  hard,  ulcerating  mass  high  up, 
as  a  rule,  in  the  rectum.  It  may  be  easier  to  reach  if  the  patient 
stands  or  squats  and  strains  down  during  examination. 

From  tuberculous  or  benign  stricture  with  or  without  ulceration, 
and  from  benign  villous  growths,  it  may  be  impossible  to  distin- 
guish cancer  without  histological  examination  of  an  excised  piece. 
Tumors  of  the  prostate  are  felt  on  the  anterior  wall  of  the  rec- 
tum and  practically  never  ulcerate. 

THE  MALE  GENITALS. 

Routine  examination  of  the  male  genitals  includes  investigation 
of  the  penis  for  the  presence  of : 

(a)  Urethral  discharge  and  its  consequences. 
(5)  Chancre. 

(c)  Chancroid 

(d)  Balanitis. 

(e)  Phimosis  or  paraphimosis. 
(/)  Periurethral  abscess. 

(<?)  Malformations. 
(A)  Cancer. 

In  the  testes  and  scrotum  we  look  for : 
(a)  Epididymitis  (gonorrhceal  or  tuberculous). 
(£)  Orchitis  (traumatic,  syphilitic,  tuberculous,  after  mumps  and 
other  infections). 

(e)  Tumors  of  the  testis  (cancer  or  sarcoma). 

(d)  Hydrocele  and  haematocele. 

(e)  Varicocele. 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS.       445 

(/)  Scrotal  hernia. 

(g)  Absence  of  one  or  both  testes. 


The  Penis. 

Urethral  discharge,  if  not  obvious,  may  often  be  brought  to  light 
by  "  stripping  "  the  urethra  forward  from  the  prostatic  region  to  the 
meatus.  If  Gram's  stain  brings  out  an  intracellular,  decolorizing 
diplococcus  in  the  exudate,  there  is  no  reasonable  doubt  of  the  pres- 
ence of  gonorrhoea. 

Chancre  ("hard  sore"),  the  primary  syphilitic  lesion,  is  a  super- 
ficial, painless,  indolent  ulcer  with  an  indurated  base  and  a  scanty 
serous  discharge.  It  is  usually  round  or  oval  and  sharply  demarked 
from  the  surrounding  tissue  by  elevated  edges.  It  is  rarely  multi- 
ple. Painless,  hard,  non-suppurating  buboes  accompany  it.  The 
glans  and  the  inner  surface  of  the  prepuce  are  the  commonest  sites. 

Chancroid  ("soft  sore")  is  like  any  other  painful,  superficial 
ulcer  without  induration,  irregular  in  shape,  often  multiple,  and 
with  abundant  discharge.  A  single,  painful  bubo  accompanies  it  in 
about  one-third  of  all  cases. 

Balanitis  (inflammation  of  the  surface  of  the  glans  penis),  usu- 
ally gonorrhoeal,  has  the  ordinary  signs  of  inflammation ;  it  often 
spreads  to  the  inner  surface  of  the  prepuce. 

Phimosis  is  a  contraction  of  the  orifice  of  the  prepuce,  so  that  it 
cannot  be  retracted  to  uncover  the  glans.  May  be  hereditary  or 
the  result  of  gonorrhoea. 

In  paraphimosis  the  prepuce  is  caught  behind  the  glans  penis  so 
that  it  cannot  be  brought  forward.  Great  oedema  of  the  neighbor- 
ing parts  usually  results. 

Peri-urethral  abscess,  usually  a  complication  of  gonorrhoea,  ap- 
pears as  a  small,  tender  swelling  on  the  under  surface  of  the  ure- 
thra. 

Malformations  are  chiefly  hypospadias  or  congenital  deficiency  of 
some  portion  of  the  lower  wall  of  the  urethra,  and  epispadias  (rare), 
a  similar  deficiency  in  the  upper  wall.  A  short,  downward  curved 
penis  is  often  associated  with  hypospadias. 


446  PHYSICAL  DIAGNOSIS. 

Cancer  of  the  penis  attacks  the  foreskin  or  the  glans,  and  has 
the  usual  characteristics  of  epithelioma  elsewhere. 

The  Testes  and  Scrotum. 

Acute  epididymitis,  usually  a  complication  of  gonorrhoea,  appears 
as  a  hot  and  tender  swelling  behind  the  testis,  often  preceded  by 
tenderness  along  the  spermatic  cord.  Acute  hydrocele  may  accom- 
pany it. 

Chronic  epididymitis,  usually  tuberculous,  is  painless  and  insid- 
ious in  onset,  and  produces  a  hard,  irregular  enlargement  low  down 
behind  one  or  both  testes,  to  which,  however,  the  process  is  apt 
soon  to  spread.  Caseation  and  involvement  of  the  skin  later  pro- 
duce a  suppurating  sinus,  which  is  often  the  first  thing  to  bring  the 
patient  to  a  physician. 

Acute  orchitis  is  often  due  to  a  blow,  to  gonorrhoea,  or  to  mumps. 
The  testis  is  symmetrically  swollen  and  tender,  but  suppuration 
rarely  follows. 

Chronic  orchitis,  often  syphilitic,  is  slow,  painless,  and  may  be 
accidentally  .discovered  as  a  slightly  irregular  induration  of  the 
testes  with  little  if  any  increase  in  size.  Ulceration  and  fistulas  are 
rare  in  the  syphilitic  form,  common  in  the  tuberculous. 

Cancer  of  the  testis  may  appear  at  any  age.  It  is  soft,  almost 
fluctuating,  and  grows  very  rapidly,  soon  involving  and  perforat- 
ing the  skin,  so  as  to  produce  an  offensive,  fungous,  granulating 
outgrowth  which  easily  bleeds.  The  inguinal  glands  are  involved. 

Sarcoma  of  the  testis,  commonest  at  puberty,  produces  a  painless, 
uniform  enlargement,  and  may  reach  great  size.  It  may  resemble 
hydrocele  or  hsematocele  and  be  mistaken  for  the  latter,  especially 
for  an  old  effusion  in  a  thickened  sac  (see  below). 

Diagnosis  depends  on  rapid  growth,  the  entire  absence  of  trans- 
lucency,  the  tendency  to  adhere  to  the  skin  and  to  present  unequal 
resistance  in  different  portions  (Jacobson).  Incision  should  be 
made  in  all  doubtful  cases. 

Hydrocele,  an  accumulation  of  serous  fluid  in  the  tunica  vagi- 
nalis,  may  depend  on  trauma  or  on  an  acute  epididymitis  or  orchi 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS,      447 

tis,  but  is  usually  chronic  and  of  unknown  cause.  It  may  be  con- 
genital and  communicate  with  the  peritoneal  cavity  or  form  part  of 
a  general  dropsy  in  heart  or  kidney  disease. 

Examination  shows  a  smooth,  tense,  fluctuating  tumor,  without 
impulse  on  cough,  usually  without  pain,  tenderness,  or  any  sign  of 
inflammation,  and,  above  all,  translucent  if  examined  with  a  hydro- 
scope  tube  or  in  a  dark  room  with  a  candle. 

If  the  fluid  is  opaque  or  bloody,  or  if  the  tunica  is  thickened, 
there  may  be  no  translucency  and  diagnosis  may  be  impossible 
without  puncture.  The  testis  lies  behind  the  effusion  and  near  its 
lower  end. 

Haimatocele  usually  follows  injury  and  produces  a  heavy,  opaque, 
non-fluctuating  tumor,  which  may  closely  resemble  sarcoma  unless 
the  history  and  evidence  of  trauma  are  clear.  Incision  or  puncture 
should  decide. 

Varicocele,  an  enlargement  of  the  veins  about  the  spermatic  cord 
and  vas  deferens,  is  easily  recognized  as  a  mass  of  tortuous  vessels, 
generally  in  the  left  side.  It  often  complicates  hypernephroma. 

Scrotal  hernia  is  usually  reducible,  tympanitic  on  percussion, 
and  gives  an  impulse  on  coughing.  If  it  consists  largely  of  omen- 
turn  it  will  be  dull  on  percussion.  The  history  of  the  case  and  the 
progression  of  the  tumor  from  above  downward  usually  make  its 
origin  clear. 

Absence  of  one  or  both  testes  from  the  scrotum  should  direct  our 
search  upward  to  the  inguinal  canal,  since  a  retained  testis  may  be 
the  seat  of  troublesome  inflammation  or  of  malignant  disease.  (For 
examination  of  the  seminal  vesicles,  see  the  Kectum,  page  443. ) 

THE  FEMALE  GENITALS. 
Methods. 

Inspection  of  the  external  genitals  is  easy  if  the  parts  are  prop- 
erly exposed  by  a  satisfactory  position  and  a  good  light.  Intravag- 
inul  inspection  needs  a  speculum  (Sims'  or  bivalve)  and  usually  an 
assistant  to  hold  it. 


448  PHYSICAL  DIAGNOSIS. 

Palpation  should  always  be  bimanual,  the  left  forefinger  in  the 
vagina  (or  in  the  rectum  if  the  hymen  is  narrow),  the  right  hand 
above  the  symphysis  pubis.  The  proper  co-operation  of  the  hands 
is  hard  to  describe  and  depends  on  practice.  The  pressure  of  the 
external  hand  helps  to  bring  the  pelvic  organs  within  reach  of  the 
examining  finger  in  the  vagina.  Unless  the  organs  can  be  thus 
grasped  or  balanced  between  the  outer  and  inner  hands,  no  satisfac- 
tory examination  is  possible.  Tenderness  may  prevent  this  or  ren- 
der an  anaesthetic  necessary,  but  gentleness  and  the  avoidance  of 
any  sudden  or  rapid  motions  do  much  to  facilitate  the  examination. 
The  left  hand,  in  making  its  way  into  the  upper  parts  of  the  vagi- 
nal vault,  should  press  only  on  the  perineum,  avoiding  the  region 
of  the  clitoris.  It  is  astonishing  how  much  pressure  can  be  borne 
without  pain,  provided  it  is  exerted  gradually  and  upon  the  peri- 
neum only.  Many  examiners  find  it  advantageous  to  rest  the  left 
foot  upon  a  stool,  with  the  left  elbow  on  the  knee. 


Lesions. 

I.  In  the  EXTERNAL  GENITALS  one  looks  for  some  of  the  same 
lesions  already  described  on  page  444,  viz. ,  chancre,  chancroid,  local 
inflammations,  and  tumors.  Only  the  commonest  and  most  impor- 
tant lesions  will  be  mentioned  here. 

(a)  In  young  children  a  suppurating  vulvo-vaginitis,  usually 
gonorrhceal,  but  non-venereal,  is  easily  recognized  by  the  abundant 
purulent  discharge. 

(£)  Local  eczema,  often  red  and  angry,  is  commonly  the  result 
of  the  irritation  of  diabetic  urine. 

(c)  Varicose  veins  and  oedema  of  the  vulva  are  common  in  preg- 
nancy and  occasionally  result  from  large  pelvic  tumors. 

(d)  Ruptured  perineum,  with  more  or  less  protrusion  of  the  vag- 
inal walls,  carrying  with  it  the  bladder  (cystocele)  or  rectum  (recto- 
cele),  is  readily  recognized  if  the  normal  anatomy  of  the  parts  is 
familiar. 

(e)  The  hymen  may  be  imperforate  with  retention  of  menstrual 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS.   449 

fluid,  or  tender,  irritated  remains  of  it  after  rupture  may  cause  pain 
and  need  removal. 

(/)  Urethral  caruncle  (a  small  vascular  papillorna  at  the  en- 
trance of  the  urethra)  is  a  bright  red  excrescence,  usually  the  size 
of  a  split  pea  or  smaller.  It  may  cause  no  symptoms  or  may  pro- 
duce irritation,  especially  during  micturition. 

(ff~)  Small  abscesses  of  the  glands  within  or  around  the  urethra 
may  cause  pain  in  coitus  or  during  micturition. 

II.  THE  UTERUS. — Only  the  commonest  lesions  will  be  dealt 
with  here,  viz. : 

1.  Laceration  and  "erosion"  of  the  cervix. 

2.  Malpositions  of  the  organ. 

3.  Endometritis. 

4.  Cancer  of  the  uterus. 

5.  Fibro-myoma  of  the  uterus. 

1.  (a)  Lacerations  of  the  cervix  following  childbirth  are  very 
common  and  frequently  produce  no  symptoms.     They  are  readily 
recognized  by  inspection  and  palpation,  and  are  often  combined 
with : 

(U)  "  JSrosions, "  an  ulcerated,  raw  surface  at  and  around  the  os 
uteri,  with  or  without  the  formation  of  small  cysts.  At  times  the 
os  assumes  a  warty,  irregular  appearance,  suggesting  cancer,  from 
which  it  can  be  distinguished  only  by  histological  examination  of  an 
excised  piece. 

2.  (a)  Malpositions  (backward   or   forward)  may  involve   the 
whole  organ  (ante-  or  retro  version)  or  represent  a  bending  of  the 
organ  upon  itself  (ante-  or  retroflexion).     These  lesions  may  be  va- 
riously combined  and  frequently  exist  without  producing  any  symp- 
toms.    Indeed,  it  is  doubtful  whether  there  is  any  single  "  normal " 
position  for  the  uterus.     Its  position  is  recognized  by  bimanual  pal- 
pation, which  should  also  determine  whether  the  uterus  is  freely 
movable  or  whether  it  is  bound  in  place  by  adhesions,  such  as  are 
very  often  found  with  backward  displacements. 

(&)  Prolapse  of  the  uterus  toward  the  vaginal  outlet  is  often  a 
result  of  pelvic  lacerations  unrepaired.     When  the  uterus  is  outside 
the  vaginal  outlet,  we  call  the  condition  procidentia. 
29 


450  PHYSICAL  DIAGNOSIS. 

(c)  Lateral  displacement  of  the  uterus  by  pressure  of  tumors  or 
traction  by  old  adhesions  is  less  common. 

3.  Endometritis  may  present  no  definite  physical  signs  except  a 
muco-purulent    discharge  (leucorrhoea,  "  whites  " )  and  perhaps  un- 
duly frequent,  profuse,  or  prolonged  menstruation.     The  slightest 
touch  of  a  uterine  sound  may  produce  bleeding.     It  often  accom- 
panies disturbances  of  digestion  and  neurasthenic  conditions,  prob- 
ably as  part  of  a  general  prostration  rather  than  as  its  cause. 

4.  Cancer  of  the  uterus  usually  attacks  the  cervix,  and  in  marked 
cases  is  easily  recognized  by  sight  and  touch  as  a  "  cauliflower  "- 
like,  fungating  mass  on  the  cervix.     In  its  early  stages  it  may  be 
confounded  with  "  erosions  "  and  inflammatory  conditions,  and  only 
microscopic  examination  can  satisfactorily  determine  its    nature. 
Profuse  hemorrhage,  especially  in  a  woman  about  the  period  of  the 
menopause,  and  the  offensive  odor  of  the  discharge  suggest  the  diag- 
nosis.    The  vaginal  wall  is  soon  involved  in  the  growth,  and  irrita- 
bility or  obstruction  in  bladder  or  rectum  may  result. 

5.  Fibro-myoma  of  the  uterus  is  by  far  the  commonest  tumor  of 
that  organ.     It  produces  hemorrhages  at  or  between  the  menstrual 
periods,  and  anaemia  results.     Otherwise  its  effects  are  those  of 
pressure  on  the  bladder  and  rectum,  or  on  neighboring  nerves  or 
vessels  (pain,  oedema). 

Birnanual  palpation  determines,  first  of  all,  the  fact  that  the 
growth  is  connected  and  moves  with  the  uterus.  This  determined 
and  cancer  excluded  by  the  absence  of  any  involvement  of  the  cer- 
vix or  of  the  vaginal  wall,  the  chief  difficulty  may  be  in  distin- 
guishing the  growth  from  a  pregnant  uterus.  Usually  its  irregular 
shape,  the  persistence  of  menses,  and  the  lapse  of  time  settle  the 
question. 

Lengthening  of  the  uterine  canal  is  an  important  confirmatory 
sign  of  fibromyouia,  but  sounds  should  never  be  passed  to  determine 
this  fact  unless  pregnancy  can  be  definitely  excluded. 

III.  FALLOPIAX  TUBES.  — Salpingitis  (acute  or  chronic)  and 
tubal  pregnancy  are  the  most  important  diseases  of  the  tubes. 

(a)  Salpingitis  is  usually  gonorrhoeal,  occasionally  tuberculous, 
sometimes  of  unknown  origin.  A  painful,  tender  swelling  or  indu- 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS.       451 

ration  in  the  region  of  the  tube,  with  or  without  fever,  chill,  or 
leucocytosis,  constitutes  the  evidence  for  diagnosis.  From  pelvic 
peritonitis  of  the  tubal  region  diagnosis  is  impossible. 

From  tubal  pregnancy  diagnosis  may  be  very  difficult,  and  sus- 
picions are  rarely  aroused  until  rupture  occurs  (vide  infra).  If  the 
signs  and  symptoms  of  pregnancy  are  absent  and  tenderness  is 
marked,  the  condition  is  usually  called  salpiugitis ;  but  even  then 
mistakes  often  occur,  as  the  menses  may  persist  in  tubal  pregnancy 
and  the  foetal  tumor  may  be  tender.  Only  when  pregnancy  can 
absolutely  be  excluded  is  diagnosis  sure. 

(b}  Tubal  ])reffnanci/,  as  just  explained,  is  rarely  to  be  diag- 
nosed until  the  growth  of  the  foetus  ruptures  the  tube — an  event 
which  usually  occurs  between  the  third  and  the  twelfth  week  of 
pregnancy.1  Sudden  pelvic  pain  with  tenderness,  vomiting,  and 
evidence  of  internal  hemorrhage  (i.e.,  pallor,  fainting,  weak,  rapid 
pulse,  thirst,  air  hunger)  suggest  the  diagnosis,  especially  if  a  tumor 
in  the  tubal  region  can  be  detected  bimanually. 

IV.  OVARIES. — h.  prolapsed  ovary  is  often  felt  during  a  vaginal 
examination,  being  recognized  by  its  size,  shape,  and  relation  to  the 
uterus. 

Ovaritis,  enlargement,  and  tenderness  of  one  or  both  ovaries  is 
iisually  part  of  tubal  disease  and  not  sharply  to  be  distinguished 
from  it  before  operation .  In  other  cases  it  is  associated  with  cyst  for- 
mation*, and  the  cysts  may  be  palpated  bimanually.  Abscess  of  the 
ovary  is  not  commonly  diagnosed,  but  is  met  with  in  operations  for 
pus  tubes. 

Ovarian  Tumors. 

(a)  Small  Tumors. — In  their  earlier  stages  these  growths  pro- 
duce symptoms  only  when  complications  arise,  i.e.,  suppuration  or 

twisting  of  the  pedicle.      Small,  suppurating  cysts  give  practically 

« 

1  If  disturbances  of  menstruation,  morning  nausea,  changes  in  the  breasts, 
and  cyanosis  of  the  vagina  are  combined  with  an  extra-uterine  tumor  and  an 
unusually  slight  uterine  enlargement,  the  diagnosis  of  tubal  gestation  may  be 
suspected  prior  to  rupture. 


452  PHYSICAL  DIAGNOSIS. 

the  same  signs  as  those  of  a  pus  tube,  and  are  recognized  only  at 
operation  or  autopsy. 

Twisted  pedicle  gives  rise  to  symptoms  and  signs  often  indistin- 
guishable from  those  of  intestinal  obstruction.  Only  the  recogni- 
tion of  the  tumor  as  ovarian  can  suggest  that  the  acute  symptoms 
may  be  due  to  twisting  of  its  pedicle. 

(#)  Large  ovarian  tumors  have  been  confused  in  my  experience 
with  pregnancy,  fibroid  of  the  uterus,  ascites,  and  tuberculous  peri- 


FiG.  201.— Huge  Ovarian  Cyst. 

tonitis.  From  these  we  may  usually  distinguish  an  ovarian  tumor 
by  its  history,  its  origin  from  one  side  of  the  belly,  by  the  shape 
of  the  belly,  the  area  of  percussion  dulness,  and  the  pelvic  examin- 
ation. 

By  the  history  we  should  attempt  to  exclude  disease  of  the 
heart,  kidney,  and  liver,  and  tuberculosis  of  any  organ,  should  in- 
quire into  the  position  of  the  tumor  in  the  earlier  stages  of  its 
growth,  and  establish  tfye  presence  or  absence  of  the  ordinary  signs 
of  pregnancy  and  of  uterine  hemorrhages  such  as  occur  with  fibroids. 

In  ascites  or  tuberculous  peritonitis  the  flanks  often  bulge  (see 
Fig.  180,  page  374),  whereas  in  ovarian  disease  the  bulging  is  central 
and  greatest  just  below  the  navel  (see  Fig.  201). 


THE  BLADDER,  RECTUM,  AND  GENITAL  ORGANS.   453 

If  by  the  history  or  by  palpation  and  percussion  we  can  deter- 
mine that  the  tumor  is  fluctuant  and  springs  from  one  side  of  the 
abdomen,  it  is  in  all  probability  ovarian.  High  psoas  abscess 
sometimes  presents  identical  signs,  but  is  associated  with  evidence 
of  spinal  tuberculosis  (see  below,  p.  491).  Moderate  ascites  or  tu- 
berculous peritonitis  leaves  an  oval,  resonant  area  about  the  navel, 
which  is  absent  with  large  ovarian  tumors ;  but  if  the  amount  of 
free  fluid  is  large,  percussion  and  palpation  may  give  results  iden- 
tical with  those  found  in  ovarian  disease. 

Vaginal  examination  may  exclude  fibroid  by  showing  that  the 
uterus  is  not  directly  connected  with  the  tumor  and  by  demonstrating 
with  a  uterine  sound  that  the  uterine  canal  is  not  elongated. 

Solid  tumors  of  the  ovary,  carcinoma,  sarcoma,  or  fibroma  are 
rarely  recognizable  before  operation  and  are  often  mistaken  for  pe- 
dunculated  uterine  fibroids.  They  are  apt  to  be  associated  with 
aseites. 


CHAPTER   XXII. 

THE   LEGS   AND   FEET. 

THE  LEGS. 

I.  Hip. 

THE  examination  of  the  hip  will  be  discussed  later  (see  page 
491). 

II.    Groin. 

In  the  groin  we  look  for  evidences  of : 

1.  Enlarged  or  inflamed  lymphatic  glands  and  scars  of  previous 
inflammation. 

2.  Hernia  and  hydrocele  of  the  cord. 

3.  Psoas  abscess. 
Less  common  are : 

4.  Retained  testis. 

5.  Filarial  lymphatic  varix. 

1.  Inguinal  Glands. — Two  sets  of  inguinal  glands  are   distin 
guished — one  arranged  along  the  lower  half  of  Poupart's  ligament ; 
the  other  lower  down,  around  the  saphenous  opening. 

(a)  The  "Poupart's  group"  are  acutely  enlarged  in  lesions  of 
the  genitals  ("bubo"  of  gonorrhoea,1  syphilis,  chancroid)  and  peri- 
neum; chronically  enlarged  in  malignant  disease  of  the  penis,  uterus 
(late),  and  other  genitalia. 

(6)  The  saphenous  group  is  enlarged  in  response  to  lesions  of  the 
thigli,  leg,  and  foot  (cuts,  wounds,  ulcers,  eczema,  etc.). 

1  The  bubo  of  gonorrhoea  often  suppurates ;  that  of  syphilis  rarely.     Hence 
a  scar  in  the  inguinal  region  suggests  an  old  gonorrhoea. 


THE  LEGS  AND  FEET. 


455 


(c)  Either  or  both  groups  may  be  enlarged  in  leukaemia,  Hodg- 
kin's  disease  (see  above,  page  30),  infectious  arthritis,  and  various 
obscure  fevers.  In  many  cases  no  cause  for  enlargement  can  be  found. 

2.  Hernia  is  diagnosed  by  the  presence  of  a  soft,  resonant,  fluc- 
tuating, usually  reducible  tumor  with  an    impulse  on  coughing. 
Hydrocele  of  the  cord  gives 

also  an  impulse  on  cough- 
ing, but  usually  shows  a 
distinct  limit  above.  On 
pulling  the  cord  the  swell- 
ing moves  too. 

3.  Psoas  abscess    (see 
Fig.  202)  presents  the  ordi- 
nary signs  of   pus  and  is 
associated   with    vertebral 
tuberculosis  (dorsal  or  lum- 
bar). 

4.  Retained      testis 
should  be  suspected  when- 
ever an  inguinal  tumor  is 
present  and  only  one  tes- 
tis is  found  in  the  scrotum. 

5.  f Hartal      Ujmphan- 

giectasis   is    generally   mis-         FIG.  2a2.-Psoas  Abscess.    (Bradford  and  Lovett.) 

taken  for  hernia  and  oper- 
ated on  as  such,  although  it  gives  no  impulse  on  coughing  and  can- 
not be  completely  reduced.     The  history  of  residence  in  the  tropics 
should   always  suggest  an  examination  of  the  blood  (at  night)  for 
nlariae. 

///.   The  Thigh. 

The  records  of  the  Massachusetts  General  Hospital  show  that 
(1)  epiphysitis  and  osteomyelitis  (septic  or  tuberculous)  are  almost 
ten  times  as  common  as  any  other  serious  lesion  of  the  thigh,  except 
fracture.  The  cases  are  to  be  divided  into  acute  septic  cases  and 
chronic,  usually  tuberculous,  cases. 


456  PHYSICAL  DIAGNOSIS. 

The  acute  septic  cases  begiu  with  severe  pain,  tenderness,  fever, 
chill,  and  leucocytosis.  Later  an  induration  and  finally  fluctuation 
appear,  and  the  abscess,  if  not  incised,  will  break  externally.  Gen- 
eral, sometimes  fatal,  septicaemia  may  take  place. 

The  chronic  tuberculous  cases  first  consult'  the  physician,  as  a 
rule,  for  sinus,  which  proves  when  explored  to  lead  to  dead  bone, 
as  do  most  of  the  sinuses  from  septic  cases. 

The  diagnosis  of  the  acute  cases  depends  chiefly  on  excluding 
arthritis  of  any  type.  Careful  examination  with  testing  of  joint 
motions  will  usually  demonstrate  that  the  pain  and  tenderness  are 
in  the  bone  and  not  in  the  joint.  The  leucocyte  count  is  but 
slightly  elevated  in  most  cases  of  arthritis,  but  is  decidedly  high, 
20,000  or  more,  in  most  cases  of  acute  osteomyelitis.  The  same  is 
true  of  the  temperature.  Monarticular  arthritis — the  only  variety 
likely  to  be  considered  in  such  a  diagnosis — is  rare  in  youth,  when 
most  cases  erf  acute  osteomyelitis  and  epiphysitis  occur. 

Whether  the  disease  starts  in  the  shaft  of  the  bone  or  in  the 
epiphysis  is  to  be  determined  by  the  seat  of  pain  and  tenderness. 

Tuberculous  cases  can  be  recognized  only  by  the  histological  ex- 
amination. Old  cases  may  be  suspected  by  the  presence  of  a  scar, 
but 

(2)  Multiple  white  scars  should  always  suggest,  though  they  are 
far  from  proving,  syphilis,  for  chronic  ulcer  above  the  knee  is  often 
due  to  gumma. 

Tumors  of  the  Thigh. 

(1)  Sarcoma  of  the  femur  is  the  commonest  and  largest  tumor 
of  the  thigh.     Among  one  hundred  and  thirty-three  tumors  of  the 
thigh  recorded  at  the  Massachusetts  General  Hospital,  sixty-six 
were  sarcoma.     A  hard,  spindle-shaped  growth  encircles  the  femur; 
the  lower  end  is  the  commonest  site,  but  any  part  of  the  bone  may 
be  affected  (see  Fig.  203).  ' 

(2)  Osteoma,  or  exostosis,  occurred  eleven  times  in  the  one  hun- 
dred and  thirty-three  cases  just  mentioned.     It  is  much  smaller  and 
of  slower  growth.     The  last  trait  usually  serves  to  distinguish  it 
from  sarcoma.     A'- ray  should  decide. 


THE  LEGS  AND  FEET. 


457 


(3)  Metastatic  cancer  of  the  upper  half  of  the  femur  may  occur 
after  cancer  of  the  breast,  but  rarely  gives  rise  to  symptoms  unless 
spontaneous  fracture  occurs — an  event  which  always  should  suggest 
cancer.      Epithelioma  of 

the  thigh  is  not  very  rare 
(twelve  cases  in  the'one 
hundred  and  thirty-three 
above  referred  to).  Its 
traits  are  those  of'  epi- 
thelioma  elsewhere. 

Tuberculosis  of  the 
knee  may  simulate  sar- 
coma of  the  lower  end  of 
the  femur,  but  sarcoma 
grows  more  r  a  p  i  d  1  y. 
The  tuberculin  test  or  an 
exploratory  incision  may 
be  necessary  to  decide  the 
diagnosis. 

(4)  Psoas    abscess   or 

hip-joint  abscess  (see  Fig.  202)  may  burrow  down  so  as  to  point  on 
the  thigh.  The  evidence  of  disease  in  the  hip  or  vertebrae  is  usu- 
ally sufficient  to  make  clear  the  diagnosis. 

Miscellaneous  Lesions  of  the  Thigh. 

(1)  Phlebitis  with  thrombosis  of  a  vein,  usually  the  saphenous, 
is  a  common  cause  for  swollen  thigh  (and  leg)  with  pain  and  tender- 
ness, especially  over  the  inflamed  vein,  where  a  cordy  induration  can 
often  be  felt.     Typhoid  fever  and  the  puerperal  state  are  the  usual 
causes.     Diagnosis  depends  on  the  presence  of  these  signs  and  causes 
and  the  absence  of  any  other  demonstrable  cause  for  inflammation. 

(2)  Meralgia  paroestlietica  means  the  presence  of  a  patch  of  an- 
aesthesia, paraesthesia,  or  hyperaesthesia  (tenderness),  with  or  with- 
out pain,  on  the  anterior  and  upper  surface  of  one  or  both  thighs 
(the  area  of  the  external  cutaneous  nerve). 


FIG.  203.— Sarcoma  of  the  Femur. 


458 


PHYSICAL  DIAGNOSIS. 


(3)  Payet's  disease  (osteitis  deformans)  presents  usually  its 
most  marked  lesions  in  the  legs  and  head,  though  most  of  the  other 
bones  are  also  affected.  In  the  leg  the  most  characteristic  lesions 

are  forward  bowing  of  the  femur 
and  tibia  with  outward  rotation 
of  the  whole  limb  (see  Fig.  204). 
The  or-ray  shows  marked  thick- 
ening of  some  areas,  with  thin- 
ning of  others. 

(4)  Intermittent  Claudication 
and11  Cramps." — Insufficient  cir- 
culation through  the  arteries  of 
the  legs  may  give  rise  to  sudden 
"  giving  way "  of  one  or  both 
during  running  or  walking,  the 
power  returning  after  a  short 
rest.  In  patients  at  rest  the 
frequent  recurrence  of  painful 
cramps  in  the  muscles  may  be 
the  only  manifestation  of  the 
disease. 

Obliteration  of  the  dorsalis 
pedis  (or  larger  arteries)  by  ar- 
teriosclerosis is  often  found,  but 


FIG.  UO4.— Paget's  Disease  (Osteitis  Defor- 
mans). Note  the  outward  and  forward 
bowing  of  legs  and  arms.  (Robin.) 


there  is  reason  to  believe  that 
local  anaemia,  due  to  vasomotor 
disturbances  or  other  causes, 
may  produce  similar  cramps 

(e.g.,  those  seen  in  ^football   players   during  a  hard  run  and  in 

pregnant  women). 

Paralyses. 

(1)  Paralysis  of  one  ley,  occurring  in  children,  is  usually  due 
to  anterior  poliomyelitis  ;  in  adults  it  usually  forms  part  of  a  hemi- 
plegia  or  is  of  hysterical  origin.  Neuritis,  due  to  alcohol,  lead, 
arsenic,  or  diphtheria,  may  affect  one  leg  predominantly,  but  both 


THE  LEGS  AND  FEET.  459 

are  usually  involved.  Cerebral  monople</!«s,  due  to  cortical  lesions 
of  the  leg  area,  are  rare.  Chorea  may  be  associated  with  a  limp, 
half -paralyzed  condition  in  one  leg,  usually  with  some  involvement 
of  the  arm  on  the  same  side,  and  the  characteristic  motions  (see 
above,  page  44)  make  the  diagnosis  clear. 

The  differential  diagnosis  of  the  other  varieties  of  rnonoplegia  is 
usually  easily  made  with  the  aid  of  a  careful  history  and  a  thorough 
examination  of  the  other  parts  of  the  body. 

(2)  Complete  paralysis  of  loth  l;j;/s  (paraplegia)   is  commonest 
in  diffuse  or  transverse  myelitis  («.</.,  in  spinal  tuberculosis  or  me- 
tastatic  cancer  with  pressure   on   the  cord),  in   multiple  sclerosis, 
spastic  paraplegia  (hereditary  or  acquired),  and  in  late  tabes.     Hys- 
teria also  may  produce  a  spastic  paraplegia,  though  monoplegia  is 
commoner  in  this  disease. 

(3)  Partial  paralysis  of  loth  legs  is  oftenest  due  to  neuritis, 
resulting    from  the   causes  mentioned  above.      The   extensors  of 
the  foot  are  especially  affected  and  toe-drop  results,   so  that  in 
walking  "  the  entire  foot  is  slapped  upon  the  ground  like  a  flail  " 
(Osier). 

DIFFERENTIAL  DIAGNOSIS. — (a)  In  diffuse  or  transverse  myelitis, 
whether  or  not  the  trouble  be  due  to  pressure,  there  are  increased 
reflexes,  anaesthesia,  usually  loss  of  control  of  the  sphincters  (in- 
voluntary urine  and  faeces),  and  often  bed-sores. 

(£)  In  spastic  paraplegia  of  any  type  the  legs  are  stiff  and  the 
reflexes  increased,  but  sensation  and  the  sphincters  are  normal  and 
there  is  no  atrophy  or  bed-sore  formation. 

(c)  In  multiple  sclerosis  there  are  usually  no  disturbances  of  sen- 
sation or  of  the  sphincters,  and  the  paralysis  is  associated  with  nys- 
tagmus, intention  tremor,  and  slow,  staccato  speech. 

(c?)  Tales  dorsalis  shows  ataxia  but  no  paralysis  until  late  in  its 
course.  The  paralytic  stage  is  preceded  by  a  long  period  character- 
ized by  lightning  pains,  bladder  symptoms,  Argyll-Robertson  pupil 
(see  page  15),  and  loss  of  knee-jerks. 

(e)  Hysteria  may  take  on  almost  any  type  of  paralysis  and  may 
deceive  the  very  elect,  but  as  a  rule  the  other  evidences  of  hysteria 
guide  the  diagnosis. 


460 


PHYSICAL  DIAGNOSIS. 


IV.   The  Knee. 

(a)  Tuberculosis,  atrophic,  hypertrophic,  and  infectious  arthri- 
tis, and  traumatic  synovitis  are  the  commonest  diseases,  hut  will  be 

described  with  other  dis- 
eases of  the  joints  (see 
page  486). 

(li)  Housemaid's 
knee  is  a  bursitis  of  the 
prepatellar  bursa  (see 
Fig.  205).  Fluctuation, 
with  or  without  heat 
and  tenderness,  and 
limited  to  the  prepatel- 
lar space,  is  diagnostic. 

(c)  Bo  AV -legs  and 
knock-knee  are  so  easy 
of  diagnosis  that  I  shall 
simply  mention  them 
here. 

V.   The  Lower  Leg. 

1.  Varicose  veins, 
with  their  results  (ecze- 
ma and  ulcer),  are  the 
commonest  lesions  of 
the  lower  leg.  The 
soft,  twisted,  purplish 
eminences  are  easily 
recognized.  Hardness  in 
such  a  vein  usually 
means  thrombosis.  It 

should  be  remembered  that  pregnancy  and  pelvic  tumors  may  pro- 
duce varicose  veins  in  the  legs. 

2.    Chronic  ulcers  of  the  lower  leg,  especially  those  in  front,  are 


FIG.  305.— Prepatellar  Bursitis  ("Housemaid's  Knee"). 


THE  LEGS   AND  FEET.  461 

usually  due  to  varicose  veins  and  the  resulting  malnutrition  of  the 
tissues.  They  leave  a  brown  scar  after  healing.  Syphilitic  ulcers 
usually  leave  a  white  scar;  they  may  occur  in  the  same  situation, 
but  are  more  common  above  the  knee  or  on  the  calf. 

3.  Syphilitic  periostitis  is  common  on  the  shaft  of  the  tibia,  and 
gives  rise  to  pain  (worse  at  night)  with  tenderness  and  some  swell- 
ing.    Later   bony   nodes   are    sometimes    formed,  similar  to  those 
already  pictured  on  the  frontal  bone. 

4.  Osteomyelitis  (acute  septic  or  chronic  tubercular)  often  starts 
on  the  head  of  the  tibia,  with  intense  pain,  tenderness,  fever,  and 
leucocytosis  (if  acute  or  septic) ;  there  results  a  general  septicaemia 
or  a  local  sinus  leading  to  dead  bone. 

5.  Sarcoma  not  infrequently  attacks  the  upper  end  of  the  tibia 
or  fibula,  producing  lesions  similar  to  those  described  in  the  femur. 

6.  (Edema  of  the  legs1  is  oftenest  due  to: 

(a)  Uucompen sated  heart  lesions,  primary  or  secondary  from 
lung  disease. 

(&)  Nephritis. 

(c)  Anaemia. 

(d)  Neuritis  (alcoholic,  beri-beri,  etc.). 
(e~)  Varicose  veins. 

(/")  Obesity,  flat-foot,  and  other  causes  of  deficient  local  circu- 
lation. 

In  some  cases  no  cause  can  be  found  ("  angioneurotic  "  oedema, 
"  essential  "  and  "  hereditary  "  oedema) .  Diagnosis  of  the  cause  of 
oedema  depends  on  the  history  and  the  examination  of  the  rest  of 
the  body. 

In  one  leg  oedema  may  be  due  to  thrombosis  of  a  vein  (see  page 
457),  to  pressure  of  tumors  in  the  pelvis  (pregnancy,  etc).,  to  hemi- 
plegia,  or  to  inflammation. 

7.  Tenderness  in  the  lower  leys  frequently  accompanies  oedema 
from  any  cause.     It  may  also  be  due  to  neuritis  or  trichiniasis,  and, 
of  course,  to  any  local  inflammation. 

1  It  is  notable  that  oedema  is  usually  greatest  in  the  front  of  the  leg  and  in 
the  back  of  the  thigh. 


462 


PHYSICAL  DIAGNOSIS. 


THE  FEET. 

1.  The  varieties  of  club-foot  are :  (a)  Eguinus,  the  heel  drawn 
up.  (&)  Yarns,  the  ankle  bent  outward,  (c)  Valgus,  the  ankle 
bent  inward  and  the  foot  outward,  (d)  Calcaneus,  the  foot  turned 
outward  and  upward. 

The  affection,  which  is  usually  congenital,  occasionally  the  result 
of  contractures  after  paralysis,  presents  no  difficulties  in  diagnosis. 


-' 


FIG.  206.-Flat-foot.    (Bradford  and  Lovett.) 


2.  Flat-foot  is  a  breaking  down  or  weakening  of  the  normal  arch 
of  the  foot,  so  that  the  print  of.  the  sole  loses  more  or  less  of  the 
normal  concavity  in  the  inner  side  (see  Figs.  206,  207,  and  208). 
There  are  usually  pain  and  tenderness  near  the  attachment  of  the 
ligaments  and  often  higher  up  on  the  leg. 


THE  LEGS  AND  FEET.  463 

3.  Tenosynovitis  of  tlte  Achilles  tendon  often  produces  pain  in 
the  tendon,  increased  by  use  and  sometimes  associated  with  palpa- 
ble creaking  or  crepitus  over  it. 

4.  Enlarged  (rachitic)  epiphyses  are  seen  at  the  lower  end  of  the 


FIG.  207.— Flat-foot.    Print  of  the  sole.    (Bradford  and  Lovett.) 

tibia  and  fibula  just  above  the  ankle-joint  in  about  forty  per  cent  of 
rachitic  cases.  The  other  signs  of  rickets  in  the  child  make  diagno- 
sis easy. 

5.  Tuberculosis  is  especially  apt  to  attack  the  ankle  bones  in 
young  persons.     It  is  recognized  by  the  usual  evidences  of  joint 
tuberculosis  (see  below,  page  494). 

6.  Epithelio-ma  of  the  ankle  has  the  characteristics  of  epitheli- 
orna  elsewhere. 


464  PHYSICAL  DIAGNOSIS. 

7.  Erythromelalgia,  or  red  neuralgia  of  the  extremities,  is  com- 
monest in  the  feet.  The  toes  (or  lingers)  are  redr  hot,  tender,  and 
painful  in  (Kaynaud's  disease  the  digits  are  cold  and  painless  or 
anaesthetic).  The  attacks  are  aggravated  by  heat  and  not  (like 
those  of  Kaynaud's  disease)  by  cold.  Such  attacks  are  probably 


FIG.  308.— Print  of  the  Soles  of  Normal  Feet.    (Bradford  and  Lovett) 

akin  to  the  condition  of  "  hot  feet "  often  seen  in  arteriosclerosis  and 
myocarditis.  The  patient  kicks  off  the  bed  clothes  from  his  feet  at 
night  on  account  of  the  burning  sensations  in  them.  Other  evi- 
dence of  insufficient  arterial  blood  supply  (e.y.,  clubbing,  intermit- 
tent claudication,  cramps,  gangrene)  may  coexist. 


THE  LEGS  AND  FEET.  465 

The  Toes. 

Many  of  the  lesions  already  mentioned  in  the  fingers  are  found 
also  in  the  toes  (e.g.,  atrophic  and  hypertrophic  arthritis,  acromegaly, 
pulmonary  osteoarthropathy,  tuberculous  or  syphilitic  dactylitis, 
tremors,  spasms,  and  choreiform  movements).  Other  lesions,  such 
as  ingrowing  toe-nail,  bunion,  hallux  valgus,  policeman's  heel,  are 
too  purely  local  to  deserve  description  here.  Excluding  these  we 
have  left : 

1.  Gout,  which  is  especially  prone  to  attack  the  metatarso-pha- 
langeal  joint  of  the  great  toe,  producing  all  the  classical  signs  of 
inflammation. 

2.  Gangrene  is  usually   the  result  of  arteriosclerosis  with   or 
without  diabetes  mellitus,  but  may  result  (as  in  the  fingers)  from 
arterial  spasm  or  local  asphyxia  (Raynaud's  disease). 

3.  Perforating   Ulcer. — In  diabetes  and  sometimes  in  tabes  a 
trophic  or  nutritional  ulcer  may  develop  in  the  toe  or  tarsus  as  a 
result  of  nerve  influences  similar  to  those  which  produce  Charcot's 
joint  or  herpes  zoster  in  the  diseases  just  mentioned.     It  is  called 
" perforating  ulcer  "  because  of  its  stubborn  progression  despite  a 
plan  of  treatment  that  checks  ordinary  infectious  abscesses.     Actual 
perforation  is  not  often  seen. 

4.  "  Tender  toes  "  after  typhoid  fever  result  from  an  infectious 
neuritis. 

5.  "Morton's  disease"  (metatarsalgia)  means  pain  in  the  tarsus 
at  a  small  spot  near  the  distal  end  of  one  of  the  three  outer  toes, 
always  associated  with  compression  of  the  foot  by  tight  boots  and 
probably  due  to  pinching  of  the  external  plantar  nerves  between  the 
metatarsal  bones.     It  is  relieved  by  proper  shoes. 

30 


CHAPTER   XXIII. 

THE    BLOOD. 
EXAMINATION  OF  THE  BLOOD. 

THE  essentials  of  blood  examination  as  a  part  of  physical  diag- 
nosis are  as  follows : 

I.  Haemoglobin  test  (Tallqvist)  in  all  cases. 

II.  Study  of  a  stained  blood  film  in  most  cases. 

III.  Total  leucocyte  count  (Thoma-Zeiss)  in  many  cases. 

IV.  Count  of  red  corpuscles  and  Widat  reaction  in  a  few  cases 

V.  Coagulation  time,  rarely. 

I  will  now  give  a  brief  account  of  each  of  these  methods  and  of 
the  interpretation  of  the  data  obtained  by  them. 

/.  Haemoglobin. 

(a)  The  Tallqvist  scale  consists  of  ten  strips  of  red- tinted  f^per 
corresponding  to  the  tint  of  a  filter  paper  of  standard  quajttfpt^hen 
saturated  with  blood  containing  ten  per  cent,  twenty  per  ceijity  .thirty 
per  cent,  etc.,  haemoglobin  up  to  one  hundred  per  cent.  -To  per- 
form the  test  we  puncture  the  lobe  of  the  ear  with  a  glover's  needle 
(not  with  sewing  needle),  saturate  a  strip  of  the  filter  paper  which 
is  bound  up  with  the  scale,  in  the  blood  of  the  patient  to  be  exam- 
ined, and  compare  the  tint  of  this  strip  with  the  different  standard 
tints  in  the  scale.  Always  saturate  at  least  half  a  square  inch  of 
filter  paper  with  blood  and  allow  it  to  dry  until  the  gloss  has  dis- 
appeared. Do  not  blot  it,  and  do  not  delay  in  making  the  com- 
parison after  the  humid  gloss  has  disappeared.  Stand  with  the 
light  behind  you  or  at  one  side  of  you ;  use  daylight  always. 


THE  BLOOD. 


407 


The  test  is  not  accurate  within  ten  degrees,  but  a  degree  of  ac- 
curacy greater  than  this  is  very  raiely  required  for  any  purpose  of 
diagnosis,  prognosis,  or  treatment.  In  rare  cases,  when  a  more 
accurate  reading  is  needed,  we  may  use  the  instrument  of  Gowers 
as  modified  by  Sahli. 

(V)  Sahli' s  instrument  see  (Fig.  209)  must  be  obtained  from  one 
of  the  firms  recommended  by  him,1  else  the  standard  solution  is 
likely  to  be  inaccurate  in  col- 
or. To  use  the  instrument 
we  first  put  a  few  drops  of 
water 2  into  the  empty  tube 
(Fig.  209,  5),  then  suck  up 
blood  with  the  pipette  (Fig. 
209,  C),  until  the  mark  1  is 
reached.  \Yipe  the  point  of 
the  pipette  and  immediately 
blow  out  the  blood  into  the 
water  at  the  bottom  of  the 

tube  (B).  Suck  this  mixture  Fm  m._Gov/ers,  H*moglobinometer.  U,  Dl- 
of  blood  and  water  back  into  lutinprtube;  C,  pipette;  D,  dropper, 

the  pipette  and  blow  it  out 

again  twice  to  cleanse  the  pipette.  Next  add  water  from  the 
dropper  (D),  a  few  drops  at  a  time,  until  the  tint  of  the  mixture 
of  the  blood  and  water  is  the  same  as  that  of  the  standard  solu- 
tion, when  both  are  looked  at  with  transmitted  light.  After 
each  addition  of  water  close  the  end  of  the  tube  with  the  thumb 
and  invert  it  twice,  then  scrape  the  thumb  on  the  edge  of  the  tube 
so  as  to  rub  off  any  moisture  deposited  there  during  the  process  of 
inversion.  As  the  tint  of  the  mixture  of  blood  and  water  ap- 
proaches that  of  the  standard  solution,  add  the  water  two  drops 
at  a  time,  and  close  the  eyes  for  a  few  seconds  between  each  two 
attempts  at  reading.  When  the  colors  in  the  two  tubes  seem  to  be 

1  Iloltx  or  Bilchi  of  Berne. 
'*  The  description  here  given  follows  Gowers. 

Sahli — "  Fill  the  empty  tube  to  the  mark  10  with  decinormal  HC1  solu- 
tion," and  blow  the  blood  into  this — then  dilute  with  water  as  above. 


468  PHYSICAL   DIAGNOSIS. 

identical,  read  off  the  figure  corresponding  with  the  meniscus  of  the 
column  of  fluid  in  the  tube.  The  resulting  figure  represents  the 
percentage  of  haemoglobin. 

(c)  The  Color  Index. — The  data  to  be  obtained  by  these  instru- 
ments stand  for  the  amount  of  the  coloring  matter  in  a  given  unit 
of  blood  when  compared  with  the  amount  in  a  similar  unit  of  nor- 
mal blood.  When  the  haemoglobin  percentage  is  low,  anaemia  is  al- 
ways present,  and  the  degree  of  anaemia  is  measured  by  the  amount 
of  reduction  in  the  haemoglobin  per  cent.  But  the  percentage  of 
haemoglobin  is  not  a  measure  of  the  number  of  corpuscles  present  in 
a  given  unit  of  blood,  for  if  the  corpuscles  are  large  and  contain  each 
of  them  a  relatively  large  amount  of  haemoglobin,  they  may  be  con- 
siderably diminished  in  number  and  yet  furnish  a  normal  bulk  of 
haemoglobin,  as  tested  by  either  of  the  instruments  described.  Thus 
in  pernicious  anaemia  the  corpuscles  are  often  so  large  that  they 
contain  nearly  one-third  as  much  again  as  a  normal  corpuscle,  so 
that  even  though  their  number  is  considerably  diminished  they  may 
carry  a  normal  amount  of  haemoglobin.  This  condition  is  known 
as  a."hiffh  color  index."  On  the  other  hand,  the  number  of  red 
corpuscles  may  be  normal,  yet  each  corpuscle  so  deficient  in  haemo- 
globin that  the  haemoglobin  in  a  given  quantity  of  blood  is  as  low 
as  forty  or  fifty  per  cent.  This  state  of  things  is  often  found  in 
chlorosis  or  in  any  form,  of  secondary  anaemia  (see  below,  page  477). 
When  the  diminution  in  the  number  of  red  corpuscles  is  greater 
than  the  diminution  of  haemoglobin,  we  say  that  the  color  index  is 
high,  meaning  that  each  corpuscle  carries  more  haemoglobin  than 
normal.  Thus  if  we  have  a  red  count  of  two  millions  and  a  half  of 
red  cells,  and  each  cell  contained  the  normal  amount  of  haemoglobin, 
the  haemoglobins-percentage  would  be  fifty,  representing  a  reduction 
in  haemoglobin  proportional  to  the  reduction  in  the  red  cells ;  but  if 
with  the  same  count  we  had  a  haemoglobin  percentage  of  seventy- 
five,  this  would  mean  that  each  corpuscle  contained  half  as  much 
again  as  compared  with  the  haemoglobin  in  normal  red  cells.  Here 
we  should  say  that  the  color  index  is  1.5.  Five  million  red  cells 
and  one  hundred  per  cent  of  haemoglobin  give  a  color  index  of  1 ;  so 
do  four  million  red  cells  with  eighty  per  cent  of  haemoglobin,  three 


THE  BLOOD.  469 

million  and  sixty  per  cent,  two  million  and  forty  per  cent,  and  so 
on.  An  example  of  low  color  index  would  be  four  million  red  cells 
with  forty  per  cent  haemoglobin,  representing  a  color  index  of  0.5; 
or  three  million  red  cells  with  thirty  per  cent  haemoglobin,  repre- 
senting again  a  color  index  of  0.5. 

The  diagnostic  significance  of  the  color  index  is  briefly  this : 
Any  diminution  in  haemoglobin  means  anaemia,  but  a  diminution  in 
haemoglobin  with  a  high  color  index  suggests,  though  it  does  not 
prove,  pernicious  anaemia,  while  a  low  color  index  points  to  chloro- 
sis or  secondary  anaemia  of  any  type.  Normal  color  index,  despite 
anaemia,  is  most  often  found  immediately  after  hemorrhage. 

//.   Study  of  the  Stained  Blood  Film. 

To  recognize  the  presence  and  the  degree  of  anaemia  one  needs 
only  the  haemoglobin  test,  but  to  determine  the  kind  of  anaemia,  to 
study  the  leucocytes,  or  to  search  for  parasites  we  need  the  stained 
blood  film.  Two  processes  are  now  to  be  described: 

1.  Preparing  the  film. 

2.  Staining. 

1.  Blood  films  may  be  spread  on  slides  or  on  cover  glasses.    The 
first  method  is  the  easier ;  the  second  gives  better  preparations.     To 
prepare  blood  films  on  slides, 
dip  two  slides  in  water  and 
rub  them  clean  with  a  towel 
or  handkerchief ;  put  a  drop 
of    blood   near   one    end  of 
one  slide,  put  the  other  slide          Slide  .^ 
against   the  drop,   and  rest 
it  evenly  upon  the  first,  as        '— 
shown   in  Fig.   210.     Next 
draw  the  upper  slide  along 

horizontally,  SO  as  to  Spread  FIG'  ^--Method  of  Spreading  Blood  Films. 

the    drop    over    the  whole 

surface  of  the  lower  slide.  The  process  may  then  be  repeated,  re- 
versing the  slides  and  using  as  a  "  spreader  "  the  one  on  which  the 


470  PHYSICAL  DIAGNOSIS. 

film  has  already  been  prepared.  This  method  is  so  simple  that  one 
can  usually  succeed  with  it  at  the  first  attempt,  but  the  corpuscles 
are  not  spread  quite  so  evenly  as  in  cover-glass  preparations  and  it 
is  somewhat  more  difficult  to  get  a  perfect  stain. 

The  cover-glass  method  requires  a  much  greater  degree  of  clean- 
liness and  manual  dexterity  than  the  slide  method.     Cover  glasses 
must  be  washed  in  water  and  then  thoroughly  polished  with  a  silk 
(not  cotton  or  linen)  handkerchief.     The  success  of  the  whole  proc- 
ess depends  upon  the  thoroughness  of  the  polishing.     Every  part 
of  the  glass  must  be  thoroughly  gone  over,  taking  care  not  to  omit 
the  corners.     This  is  rather  tedious  and  often  drives  us  to  use 
slides,  which  can  be  much  more  quickly 
^^^^"      prepared.      With    cover  glasses  we  must 
/  - — — L  remove  not  only  all  dirt  and  grease,  but 

/  f*' •    also  every  speck  of  dust  or  lint  which  may 

settle  upon  them.     The  use  of  silk  as  a 
polisher  reduces  this  difficulty  to  a  mini- 
tn. 
Having  prepared  the  cover  glasses  in 


l^  I settle  upon  them.     The  use  of  silk  as  a 


1     * \  mum. 

this  way.  the  next  point  is  to  keep  them 
FIG.   211.— Proper    Method    of  J  ' 

HoidinR  a  cover  Glass,          both  clean  and  dry  during  the  process  of 
spreading  the  blood.      We  must   always 

hold  them  as  in  Fig.  211,  and  never  touch  any  part  of  their  sur- 
faces with  the  fingers.  Any  one  whose  fingers  tend  to  get  moist 
must  handle  the  cover  glasses  with  forceps,  but  most  of  us  will  al- 
ways use  our  fingers,  despite  the  warnings  of  our  Teutonic  brethren. 
Holding  a  cover  glass  as  in  Fig.  211,  touch  the  centre  of  it  with  the 
tip  of  a  drop  of  blood  as  it  issues  from  a  puncture,  taking  care 
not  to  touch  the  skin  of  the  ear  itself;  then  drop  this  cover  glass 
(blood  side  downward)  upon  a  second  cover  glass  in  such  a  posi- 
tion that  their  corners  do  not  match.  If  the  covers  are  quite  clean 
and  free  from  dust,  the  blood  drop  will  at  once  spread  so  as  to 
cover  the  whole  surface  of  the  glasses.  The  instant  it  stops  spread- 
ing, take  hold  of  the  upper  cover  glass  by  one  corner  and  slide  it 
rapidly  off  without  lifting  it  or  tilting  it  at  all.  This  needs  some 
practice,  and^some  men  never  learn  it ;  hence  the  use  of  slides. 


THE  BLOOD.  471 

Films  so  prepared  will  keep  for  a  long  time  without  deteriorat- 
ing, especially  if  the  air  is  excluded. 

2.  Staining. — The  introduction  of  the  Romanowsky  method  of 
staining  (Nocht's,  Ziemaim's,  Jenner's,  Leishman's,  Wright's)  ena- 
bles us  to  dispense  with  all  other  blood  stains  and  greatly  shortens 
the  time  of  the  process.  Wright's  stain  is  identical  with  Leish- 
man's except  in  the  method  of  preparation,  which  Wright  has  consid- 
erably simplified,  and  as  either  of  these  mixtures  can  be  obtained 
ready  made  of  any  of  the  larger  dealers  in  physicians'  supplies,  I 
shall  not  describe  the  method  of  making  it.  Reliable  stains  can 
always  be  obtained  from  the  Massachusetts  General  Hospital  in  Bos- 
ton. An  ounce  bottle  will  stain  hundreds  of  specimens. 

To  stain  a  cover-glass  film,  grasp  it  with  Cornet's  forceps,  rest 
the  forceps  on  the  sink  so  that  the  film  side  is  upward  and  is  ap- 
proximately horizontal.  Draw  a  little  of  Wright's  or  Leishman's 
stain  into  a  clean  medicine-dropper  and  squeeze  out  upon  the  film 
enough  to  flood  its  surface. 

(a)  Allow  the  stain  to  act  for  one  minute  ;  during  this  time  the 
methylic  alcohol  contained  in  it  fixes  the  film  upon  the  cover  glass. 

(&)  Next  add  distilled  water  from  a  clean  medicine-dropper  until 
a  greenish  metallic  lustre  appears  like  a  scum  upon  the  surface  of 
the  stain.  Usually  about  six  or  eight  drops  of  water  are  needed  if 
we  are  using  a  seven-eighths-inch  cover  glass.  The  stain,  so  di 
luted  with  water,  should  remain  upon  the  cover  glass  about  two 
minutes.  The  exact  time  does  not  matter. 

(c)  Next  wash  off  the  stain  with  water  cautiously  and  let  the  film 
remain  in  clean  water  for  about  a  minute  more  or  until  it  takes  on 
a  light  pink  color.  Dry  gently  with  blotting  paper  and  mount  in 
Canada  balsam. 

This  whole  process  can  be  completed  inside  of  five  minutes,  and 
I  know  of  no  other  staining  method  at  once  so  rapid,  so  reliable, 
and  so  widely  applicable.  It  brings  out  all  the  minutiae  of  the  red 
corpuscles,  leucocytes,  and  blood  parasites,  and  for  clinical  work  no 
other  stain  is  needed. 

APPEARANCE  OF  FILMS  so  STAINED. — 1.  The  normal  red  corpus- 
cles appear  as  round  discs  with  pale  centres.  Their  color  depends 


472 


PHYSICAL  DIAGNOSIS. 


upon  the  length  of  time  that  we  continue  the  washing  with  clear 
water  after  the  staining  mixture  has  been  poured  off,  and  varies 
from  brown  through  pink  to  golden  yellow. 

(a)  Poikilocy tosis  means  the  appearance  in  the  blood  of  red  cells 
variously  deformed,   sausage    shaped,   battledore   shaped,  oblong, 
pear  shaped,  etc.     It  is  always  associated  with  abnormalities  in  the 
size  of  the  corpuscles,  so  that  dwarf  forms  and  giant  forms  appear. 

(b)  Polychromasia  (or  polychromatophilia)  refers  to  abnormal 
staining  reactions  in  the  red  corpuscles,  whereby  isolated  individ- 
uals take  on  a  brownish  or  purplish  tint,  sharply  contrasted  with 
the  pink  or  yellow  of  the  corpuscles  around.     If  this  brownish  or 
purplish  tint  occurs  in  all  the  corpuscles,  it  has  no  pathological  sig- 
nificance, but  merely  means  that  the  staining  has  been  incorrectly 
performed. 

(c)  "  Stippling  "  refers  to  fine,  dark-blue  dots  scattered  over  the 
pink  surface  of  a  red  corpuscle,  as  if  a  charge  of  fine  shot  had  been 
fired  into  it. 

All  the  abnormalities  just  described  are  to  be  found  in  any  of 

the  types  of  severe  anaemia, 
whether  primary  or  secondary, 
but  stippling  may  also  be  found 
without  anaemia  in  some  cases 
of  lead  poisoning,  and  is  there- 
fore useful  as  a  confirmatory 
sign  in  cases  of  this  disease. 

Nucleated  red  corpuscles  are 
divided  into  two  main  varieties : 
(1)  normoblasts,  which  are  of 
the  size  of  normal  corpuscles ; 
and  (2)  megaloblasts,  which  are 
larger  than  normal  corpuscles 

(see  Fig.   212).     The   nucleus 
FIG.  212.— Nucleated  Ked  Cells,    m,  m,  Megalo-       v 

blasts;  n,  normobiast ;  s,  stippled  ceil.  of  the  normoblast  is  generally 

small  and  deeply  stained,  navy 

blue.  In  the  megaloblast  the  nucleus  may  have  the  same  charac- 
teristics or  may  be  much  larger  and  paler,  with  a  distinct  intrami- 


THE  BLOOD. 


473 


clear  network.  The  protoplasm  of  both  varieties  is  often  discol- 
ored, murky,  gray,  or  even  blue,  and  sometimes  stippled,  so  that 
by  beginners  the  cell  may  be  mistaken  for  a  leucocyte.  The  mis- 
take may  be  avoided,  however,  after  some  experience.  In  the  pro- 
toplasm of  nucleated  cells 
there  are  often  concentric 
rings  like  the  layers  in  an 
oyster  shell,  and  their  outline 
is  usually  more  irregular  than 
that  of  any  leucoctye.  Fur- 
ther points  of  differentiation 
must  be  learned  by  practice. 

2.  Leucocytes. — In  normal 
blood  four  main  varieties  may 
be  distinguished : 

(a)  Polynuclears  or  poly- 
morphonuclear  neutrophiles. 

(6)  Lymphocytes  (large 
and  small). 

(c)  Eosinophiles. 

(d~)  Mast  cells. 

(a)  Polynuclears.  —  The 
deeply  stained,  markedly  con- 
torted nucleus  assumes  a  great 
variety  of  shapes  in  different 
cells,  and  is  surrounded  by  a 
pinkish  protoplasm  studded 
with  spots  or  granules  just 
large  enough  to  be  distin- 
guished under  the  oil  immer- 
sion and  slightly  deeper  in 
tint  than  the  protoplasm  FIG.  ais.-a,  Leucocytosis  <40,ooo); 

x  clears  in  a  field,    b,  Lymphatic 

around     them.        These     cells       polynuclear;    m,    megaloblast;     e.   eosinophile. 
make    up     about     two -thirds       Twenty-one  lymphocytes  in  this  Held. 

(sixty  to  seventy  per  cent]  of 

all  the  leucocytes  present  in  the  blood  (see  Fig.  213,  «). 


sixteen  polynu- 


4^4  PHYSICAL  DIAGNOSIS. 

(&)  Lymphocytes. — The  smallest  variety  is  about  the  size  of  a 
red  cell,  and  consists  of  a  round  nucleus  stained  deep  blue  and  sur- 
rounded by  a  very  narrow  rim  of  pale,  bluish-green  protoplasm. 
In  the  larger  forms  the  nucleus  occupies  much  less  space  relatively, 
is  often  less  deeply  stained,  and  may  be  indented.  The  latter  vari- 
ety is  sometimes  burdened  with  the  useless  name  of  "  transitional 
cell,"  a  term  which  in  my  opinion  should  be  given  up,  since  all 
lymphocytes  are  transitional.  In  the  protoplasm  of  the  larger  vari- 
eties of  lymphocyte  one  often  sees  a  sprinkling  of  fine  pink  gran- 
ales.  From  twenty-Jive  to  thirty-Jive  per  cent  (or  about  one-third) 
of  all  leucocytes  belong  to  the  lymphocyte  group — classing  all  sizes 
together  (see  Fig.  213,  b}. 

(c)  EosinopUiles. — The  nualeus  is  irregularly  contorted  and  at- 
tracts very  little  notice,  owing  to  the  very  brilliant  pink  color  and 
relatively  large  size  of  the  granules  in  which  it  is  immersed.  The 
outline  of  the  cell  is  more  irregular  than  that  of  any  other  leuco- 
cyte, and  its  granules  often  become  broken  away  and  scattered  in 
the  technique  of  spreading  the  blood.  The  eosinophiles  make  up 
approximately  one  per  cent  of  the  leucocytes  of  normal  blood. 

(<Z)  Mast  Cells. — The  shape  of  the  nucleus  can  rarely  be  made 
out,  and  the  main  characteristic  of  the  cell  is  the  presence  of  large 
dark  granules,  stained  blue  or  plum  color,  sometimes  almost  black, 
and  arranged  most  thickly  about  the  margin  of  the  cell.  Mast 
cells  are  very  scanty  in  normal  blood  and  make  up  not  more  than 
one-half  of  one  per  cent  of  the  leucocytes. 

Other  varieties  of  leucocytes  which  appear  in  the  blood  only  in 
disease  will  be  mentioned  later. 

3.  Blood  Plates.  —  In  the  normal  blood  film,  stained  as  directed 
above,  one  finds,  beside  the  red  corpuscles  and  the  different  varie- 
ties of  leucocytes,  a  varying  number  of  bodies,  usually  about  one- 
third  the  diameter  of  a  red  corpuscle,  irregularly  oval  in  shape, 
staining  dark  red  or  blue  and  tending  to  cohere  in  bunches.  Occa- 
sionally larger  forms  occur,  and  in  these  a  vague  network  and  some 
hints  of  a  nucleus  .may  be  traced. 

The  significance  of  these  bodies  is  unknown  and  they  have  at 
present  no  importance  in  medicine,  although  they  not  infrequently 


THE  BLOOD. 


475 


lead  to  mistakes,  because,  when  lying  on  top  of  a  red  corpuscle, 
they  bear  a  slight  resemblance  to  a  malarial  parasite. 


III.    Counting  the  White  Corpuscles. 

The  instrument  used  all  over  the  world  at  the  present  day  is  the 
pipette  of  Thoma-Zeiss,  in  which  the  blood  is  diluted  either  ten  or 
twenty  times.  The  diluting  solution  is  one-half  of  one  per  cent 
glacial  acetic  acid  in  water.  This  diluting  solution  often  accumu- 
lates spores  and  be- 
comes cloudy.  As  soon 
as  this  happens  a  fresh 
bottle  should  be  pre- 
pared. After  a  rather 
deep  puncture  blood  is 
sucked  up  to  the  mark 
point  .5  on  the  pipette, 
which  is  then  immersed 
in  the  diluting  solution 
and  suction  exerted  un- 
til the  mixture  is  drawn 
up  to  the  point  marked 
11.  This  gives  a  dilu- 
tion of  one  to  twenty. 
By  drawing  blood  up 
to  the  point  marked  1, 
instead  of  to  the  point 

marked  .5,  we  obtain  a  dilution  of  one  to  ten.  After  this  the  ends 
of  the  pipette  can  be  closed  with  a  rubber  band,  and  the  blood,  so 
shut  in,  can  be  kept  or  transported  without  loss  or  change. 

When  we  are  ready  to  make  the  count,  the  rubber  band  is  re- 
moved and  the  pipette  rolled  in  the  fingers  rapidly  back  and  forth 
for  about  one  minute,  to  mix  up  the  contents  of  the  bulb  thoroughly 
and  evenly.  Next  blow  out  three  drops,  in  order  to  get  rid  of  the 
pure  diluting  solution  which  is  in  the  shank  of  the  pipette.  Then 
put  upon  the  circular  disc  of  the  counting  chamber  a  drop  of  the 


FIG.  214.— Indicating  an  Order  in  which  the  Squares  may 
be  Counted. 


476  PHYSICAL  DIAGNOSIS. 

mixture  from  the  bulb  of  the  pipette.  This  drop  must  be  of  such  a 
size  that  when  the  cover  glass  (see  Fig.  215  Ji)  is  let  down  upon  it ' 
the  drop  will  cover  at  least  nine-tenths  of  the  circular  disc  and  not 
spill  into  the  moat  around  it.  The  size  of  this  drop  can  only  be 
learned  by  practice.  After  about  five  minutes  the  leucocytes  will 
have  settled  upon  the  ruled  space  which  occupies  the  centre  of  the 
floor  of  the  counting  chamber,  and  the  count  can  then  be  begun, 
using  preferably  a  No.  5  objective  of  Leitz  or  a  DD  of  Zeiss.  The 
whole  ruled  space  should  be  counted,  and  after  a  little  practice  this 
takes  not  more  than  five  minutes.  I  usually  begin  my  count  in  the 
left  upper  corner  of  the  ruled  space  and  proceed  in  the  direction  in- 


A  c 

FIG.  215.— Thoma-Zeiss  Counting  Slide.    A,  Ruled  disc :  B,  cover-glass ;  C,  moat. 

dicated  by  the  serpentine  arrow  in  Fig.  214.  In  normal  blood  one 
finds  from  thirty  to  fifty  leucocytes  in  the  whole  ruled  space.  The 
number  of  leucocytes  per  cubic  millimetre  is  obtained  by  multiply- 
ing this  figure  by  200.  Thus  if  the  number  of  leucocytes  counted 
is  35,  the  number  in  a  cubic  millimetre  of  blood  is  35  x  200  =  7,000. 
If  great  accuracy  is  needed,  a  second  count  with  a  fresh  drop  should 
be  made  and  the  average  of  the  two  taken ;  but  in  ordinary  clinical 
work  this  does  not  seem  to  me  necessary,  for  the  amount  of  error, 
although  considerable,  is  not  such  as  to  affect  our  diagnostic  infer- 
ences. 

IV.    Counting  the  Red  Corpuscles. 

Perhaps  once  in  every  twenty-five  or  fifty  cases  that  one  sees  it 
is  well  to  know  the  number  of  red  corpuscles.  They  can  then  be 
counted  with  the  Thoma-Zeiss  pipette  which  is  made  for  the  pur- 
pose, and  so  arranged  that  the  blood  may  be  diluted  one  to  two  hun- 

1  To  avoid  air  bubbles  lower  the  cover  glass  with  aid  of  a  needle  as  in 
mounting  microscopic  specimens.  This  must  be  done  as  quickly  as  possible 
after  the  drop  has  been  adjusted  on  the  counting  disc. 


THE  BLOOD.  477 

dred.  The  technique  is  exactly  that  described  in  the  last  section, 
except  that  we  need  less  blood  and  use  a  different  diluting  solution. 
I  am  accustomed  to  use  a  mixture  suggested  by  Gowers,  made  up 
as  follows : 

Sodium  sulphate gr.  cxii. 

Dilute  acetic  acid 3  i. 

Water §  iv. 

Blood  is  sucked  up  to  the  mark  0.5  and  then  Gowers'  solution 
to  the  mark  101.  After  the  drop  has  been  adjusted  in  the  counting 
chamber  and  the  corpuscles  have  settled  upon  the  ruled  space,  we 
usually  count  a  field  of  twenty-five  small  squares  at  each  of  the 
four  corners  of  th'e  whole  ruled  space.  The  figure  so  obtained  is 
multiplied  by  8,000.  The  result  is  the  number  of  corpuscles  per 
cubic  millimetre. 

INTERPRETATION  OF  THE  RESULTS  so  OBTAINED. 
1.    Secondary  Ancemia. 

The  haemoglobin  is  usually  reduced  more  than  the  count  of  red 
corpuscles,  giving  a  low  color  index.  In  mild  cases  the  haemoglobin 
may  fall  as  low  as  forty  per  cent  before  the  red  corpuscles  show  any 
considerable  diminution.  In  severe  cases  the  red  cells  fall  to  3,000,- 
000,  2,000,000,  and  occasionally  even  to  1,000,000  or  below  it; 
but  the  haemoglobin  usually  suffers  even  more  severely. 

The  leucocytes  may  be  normal,  increased,  or  diminished,  de- 
pending on  the  cause  of  the  anaemia.  Thus  in  anaemia  due  to 
chronic  suppurative  hip-disease  the  leucocytes  are  often  increased  to 
20,000  or  30,000,  while  in  malarial  anaemia  the  leucocytes  are  often 
subnormal.  There  are  no  characteristic  changes  in  the  differential 
count,  which  varies  with  the  underlying  disease. 

The  changes  seen  in  the  stained  blood  film  are  briefly :  Poikilo- 
cytosis,  abnormal  staining  of  the  red  corpuscles,  and  the  presence 
of  nuclei  either  in  normal-sized  corpuscles  (normoblasts)  or  in  giant 
corpuscles  (megaloblasts).  The  degree  of  poikilocytosis  and  abnor- 
mal staining  reaction  is  proportional  to  the  severity  of  the  anaemia. 
In  mild  cases  we  find  only  normoblasts,  and  those  only  after  a  long 


478  PHYSICAL  DIAGNOSIS. 

search ;  in  severe  cases  we  may  find  megaloblasts  as  well,  but  almost 
invariably  these  cells  are  fewer  than  the  normoblasts. 

The  commonest  causes  for  secondary  or  symptomatic  anaemia 
are  as  follows : 

(a)  Hemorrhage — gastric,  hemorrhoidal,  traumatic,  puerperal, 
etc. 

(£)  Malaria,  more  rarely  sepsis  or  other  infections. 

(c-)  Malignant  disease. 

(c?)  Chronic  suppurations. 

(e)  Chronic  glomerulo-nephritis. 

(/)  Cirrhosis  of  the  liver. 

(<7)  Poisons,  especially  lead. 

(A)  Chronic  dysentery. 

(t)  Intestinal  parasites. 

It  is  important  to  remember  that  insufficient  food  or  even  star- 
vation does  not  produce  anaemia,  and  so  far  as  we  know  no  form  of 
bad  hygiene  has  any  notable  effect  upon  the  blood.  Persons  may 
grow  very  pale  under  bad  hygienic  conditions,  but  their  blood  is 
usually  not  affected  unless  one  of  the  diseased  conditions  men- 
tioned above  is  present. 

2.    Chlorosis. 

The  blood  is  practically  identical  with  that  just  described, 
though  the  color  index  is  sometimes  lower,  poikilocytosis  less 
marked,  and  nucleated  red  cells  fewer.  The  pallor  of  the  centres 
of  the  cells  ("  achromia")  is  often  very  marked.  The  leucocytes  are 
generally  normal  and  the  differential  count  practically  so,  although 
the  percentage  of  polynuclear  cells  is  often  low  with  a  corresponding 
relative  increase  of  lymphocytes. 

3.  Pernicious  Anaemia. 

The  number  of  red  cells  is  usually  below  2,000,000  when  the 
case  is  first  seen.  The  color  index  is  high  and  the  leucocyte  count 
subnormal.  The  stained  specimen  shows  very  marked  deformities 


THE  BLOOD.  479 

and  abnormal  staining  reactions  in  the  red  cells,  with  a  tendency  to 
the  predominance  of  large  forms.  Many  of  the  latter  contain  nu- 
clei ("  megaloblasts  "),  and  a  smaller  number  of  normal-sized  cells 
also  contain  nuclei  ("normoblasts"). 

The  polynuclears  are  relatively  diminished,  with  a  correspond- 
ing relative  increase  in  the  lymphocytes. 

In  the  remissions  which  form  so  important  a  feature  of  the 
course  of  pernicious  anaemia,  the  blood  is  generally  transformed 
until  it  is  almost  or  quite  normal.  In  the  subsequent  fall  it  may 
take  on  all  the  features  of  secondary  anaemia  or  chlorosis,  and  lead 
to  unavoidable  errors  in  diagnosis  and  prognosis.  Fortunately  cases 
are  rarely  seen  for  the  first  time  at  this  (non-characteristic)  stage. 

INTERPRETATION  OF  THE  RESULTS  OF  THE  LEUCOCYTE  COUNT  AND 
DIFFERENTIAL  COUNT. 

By  combining  the  facts  obtained  by  the  total  white  count  and 
the  differential  count,  we  can  estimate  the  number  of  each  variety 
of  leucocyte  contained  in  a  cubic  millimetre  of  blood.  Thus  with 
10,000  white  corpuscles,  70  per  cent  of  which  are  polynuclear  (as 
seen  in  the  stained  film),  we  have  7,000  polynuclear  cells  per  cubic 
millimetre,  which  may  be  considered  the  upper  normal  limit.  Any 
number  greater  than  this  should  be  considered  as  a  leucocijtosis.  In 
a  similar  way  we  can  say  that  any  number  greater  than  3,500  is  above 
the  normal  limit  for  lymphocytes  and  constitutes  a  lympliocytosis, 
while  eosinophilia  is  present  whenever  the  number  of  eosinophiles  is 
more  than  400  per  cubic  millimetre.  It  is  much  better  to  use  these 
absolute  numbers  than  to  rely  upon  percentages.  If  we  say,  for 
example,  that  3  per  cent  of  eosinophiles  is  within  normal  limits,  we 
shall  make  an  error  now  and  then  in  cases  of  myelogenous  leukae- 
mia, in  which,  with  a  total  count  of  500,000  leucocytes,  3  per  cent  of 
eosinophiles  would  amount  to  a  total  of  15,000  per  cubic  millimetre, 
or  nearly  thirty  times  the  normal  number.  Errors  are  also  common 
in  the  opposite  direction.  For  example,  in  typhoid,  with  a  total 
leucocyte  count  of  3,000,  the  lymphocytes  may  reach  60  per  cent 
and  yet  be  well  within  the  normal  limits,  for  GO  per  cent  of  3,000  is 


480  PHYSICAL  DIAGNOSIS. 

only  1,800.     In  this  case  the  apparent  lymphocytosis  is  due  to  an 
absolute  decrease  in  poly  nuclear  cells. 

For  the  reasons  here  given  it  seems  to  me  best  to  use  the  follow- 
ing definitions : 

1.  Leucocytosis  is  an  increase  in  the  polynuclear  cells  beyond 
the  normal — 7,000. 

2.  Lymphocytosis  is  an  increase  of  lymphocytes  beyond  the  nor- 
mal tipper  limit— 3,500. 

3.  Eosinophilia  is  an  increase  of  eosinophiles  beyond  the  normal 
upper  limit — 500  per  cubic  millimetre. 

Occurrence  of  Leucocytosis. 

Leucocytosis,  like  fever,  occurs  in  a  great  variety  of  conditions, 
of  which  the  following  are  the  most  important: 

1.  In  infectious  diseases — except  typhoid,  malaria,  uncomplicated 
tuberculosis,   measles,  smallpox    (prior    to    the   pustular   stage), 
mumps,  German  measles,  and  influenza. 

2.  In  a  variety  of  toxcemic  conditions,  such  as  uraemia,  hepatic 
toxaemia,  diabetic  coma,  rickets,  and  poisoning  by  illuminating  gas. 

3.  In  a  minority  of  cases  of  malignant  disease,  especially  sar- 
coma. 

4.  After  violent  muscular  exertion,   including  parturition,  and 
after  cold  baths  or  massage. 

There  is  in  all  probability  no  constant  leucocytosis  in  pregnancy 
or  during  digestion. 

Leucocytosis  is  most  often  of  value  in  the  differential  diagnosis 
between  typhoid  fever  or  malaria  on  the  one  hand,  and  pyogenic 
infections  (meningitis,  appendicitis,  sepsis,  pneumonia)  on  the  other. 
A  leucocyte-chart  is  often  of  value  in  judging  whether  a  local  sup- 
purative  process,  such  as  appendicitis,  is  advancing  or  receding,  or 
whether  pus-pocketing  has  taken  place.  By  a  leucocyte-chart  is 
meant  a  series  of  leucocyte  counts  at  short  intervals — twelve, 
twenty-four,  or  forty-eight  hours.  When  taken  in  connection  with 
the  other  clinical  data,  a  leucocyte  chart  is  often  of  the  greatest 
value,  especially  in  following  the  course  of  any  disease ;  to  a  less 


THE  BLOOD.  481 

extent  in  diagnosis.  In  internal  medicine  leucocyte  counts  are 
especially  useful  in.  febrile  conditions,  in  the  great  majority  of  which 
they  assist  the  diagnosis. 

Certain  exceptions  to  the  rules  above  given  must  be  remem- 
bered : 

1.  Quiescent,  thickly  encapsulated  collections  of  pus,  in  which 
the  bacteria  have  died  or  lost  their  virulence,  usually  produce  no 
leucocytosis.     In  this  group  come  some  of  the  abscesses  of  the  liver 
or  about  the  kidney,  and  a  few  cases  of  appendicitis. 

2.  The  most  virulent  and  overwhelming  infections  are  apt  not 
to  be  accompanied  by  leucocytosis.     Thus,  for  example,  the  most 
virulent   cases   of   pneumonia,   diphtheria,    or   general    peritonitis 
often  run  their  course  without  leucocytosis. 

Lymphocytosis. 

Only  in  two  diseases  does  well-marked  lymphocytosis  occur :  1. 
Lymphatic  leukaemia.  2.  Whooping-cough  and  its  complications 
(many  cases). 

Occasionally  lymphocytosis  occurs  in  rickets,  hereditary  syphi- 
lis, and  anything  that  produces  debility  in  children.  Lymphocyto- 
sis is  of  value  chiefly  in  the  differentiation  of  lymphatic  leukaemia 
from  other  causes  of  glandular  enlargement. 

Eosinophilia. 

The  eosinophiles  are  increased  chiefly  in: 

1.  Bronchial  asthma. 

2.  Chronic  skin  diseases. 

3.  Diseases  due  to  animal  parasites  (trichiniasis,  uncinariasis, 
filariasis,  hydatid  disease,  Bilharzia  disease,  trypanosorniasis,  and 
with  most  of  the.  intestinal  worms"). 

4.  Myelogeiious  leukaemia. 

There  seems  to  be  also  some  vague  connection  between  eosin- 
ophilia  and  diseases  of  the  female  genital  tract  (except  cancer  and 
ribromyoma  of  the  uterus). 
31 


482 


PHYSICAL  DIAGNOSIS. 


LEUKAEMIA. 

Two  forms  are  distinguished,  though  the  distinction  is  chiefly  a 
clinical  one:   (a)  Myeloid  and  (b)  lymphoid. 


1.  Myeloid  Leuk&mia. 

The  leucocytes  are  usually  about  250,000  per  cubic  millimetre 
when  the  case  is  first  seen,  but  often  run  much  higher,  and  some- 
times lower.  There  is  no  an- 
aemia in  the  earliest  stages; 
later  moderate  secondary  an- 
seniia  develops. 

The  differential  count  shows 
an  extraordinary  variety  of 
types,  including  many  not  seen 
in  normal  blood  (see  Fig.  216). 
The  majority  of  the  leucocytes 
are  polynuclears,  but  many  of 
these  are  atypical  in  size  or  in 
the  shape  of  their  nucleus. 
From  20  to  40  per  cent  of  the 
leucocytes  are  myelocytes  (or 
mononuclear  neutrophiles),  the 
"  infantile  "  form  of  the  poly- 
nuclear  cell.  Lymphocytes  are 

absolutely  normal  or  increased,  but  their  percentage  is  low,  on  ac- 
count of  the  greater  increase  of  the  other  forms.  Eoslnophiles  are 
absolutely  much  increased,  though  the  percentage  is  not  much  above 
normal.  Mast  cells  are  more  numerous  than  in  any  other  disease 
(1  to  12  per  cent,  out  of  an  enormous  total  increase).  Normoblasts 
are  usually  very  numerous;  megaloblasts  scanty. 

Under  the  influence  of  intercurrent  infections  or  after  ic-ray 
treatment  the  blood  may  return  to  normal. 


FIG.  216.— Myelogenous  Leukaemia,  m,  Myelo- 
cytes;  p,  polynuclear ;  b,  mast  cell;  n,  normo- 
blast. 


THE  BLOOD.  483 

2.   Li/mphoid  Leukcemia. 

The  total  increase  of  leucocytes  is  usually  much  less  than  in  the 
other  type  of  leukaemia — 40,000  or  80,000 — or  less  in  -average  cases. 
The  differential  count  shows  an  overwhelming  proportion  of  lymph- 
ocytes—90  to  99.9  per  cent  as  a  rule.  In  the  acute  forms  of  the 
disease  the  large  lymphocytes  predominate;  in  chronic  cases  the 
small  forms. 

The  blood-film  is  monotonous  in  contrast  with  the  wonderful 
variety  seen  in  niyelogenous  leukaemia  (see  Fig.  213,  b). 

V.    The  Widal  Reaction. 

(a)  Technique.  Among  the  numerous  agglutinative  reactions 
between  the  serum  of  a  given  disease  and  the  micro-organism  pro- 
ducing that  disease,  only  one  has  yet  attained  Avide  use  in  clinical 
medicine,  viz.,  the  so-called  Widal  reaction  in  typhoid  fever. 

There  are  many  ways  of  performing  this  reaction,  but  in  my 
opinion  the  following  is  the  best: 

Measure  out  in  two  small  test  tubes  ten  drops  and  fifty  drops 
respectively  of  a  highly  motile  twelve-  to  twenty-four-hour  bouillon 
culture  of  typhoid  bacilli,  in  which  the  bacilli  have  no  tendency  to 
adhere  spontaneously  to  each  other.  Carry  these  tubes  and  a  mi- 
croscope to  the  bedside,  puncture  the  patient's  ear  as  usual,  and 
draw  a  little  blood  into  a  medicine-dropper  of  the  same  size  as  that 
used  in  measuring  out  the  typhoid  culture.  Expel  one  drop  of 
blood  into  each  of  the  tubes  containing  typhoid  culture,  and  exam- 
ine a  drop  of  each  mixture  between  a  slide  and  cover  glass  with  a 
high-power  dry  lens.  If  within  fifteen  minutes  clumping  has 
taken  place  in  the  1 : 10  mixture,  or  if  within  one  hour  clumping 
has  taken  place  in  the  1 :  50  mixture,  the  reaction  may  be  consid- 
ered positive.  By  clumping  I  mean  an  agglutination  of  the  bacilli 
into  large  groups  and  the  complete  or  nearly  complete  cessation  of 
motility. 

If  it  is  inconvenient  to  carry  the  culture  and  the  microscope  to 
the  bedside,  ten  or  twenty  drops  of  blood  may  be  milked  out  of  the 
ear  and  collected  in  a  test  tube  (a  three-inch  test  tube  of  small  call- 


484  PHYSICAL  DIAGNOSIS. 

bre  is  best).  After  clotting  lias  taken  place,  if  the  edges  of  the  clot 
are  separated  from  the  glass  with  a  needle  or  a  wire,  a  few  drops  of 
serum  will  exude,  and  this  serum  can  be  mixed  with  the  bouillon 
culture  in  the  manner  already  described. 

Less  reliable,  in  my  opinion,  is  the  use  of  blood  dried  upon  glass 
or  glazed  paper  in  large  drops  and  subsequently  dissolved  in  the  cult- 
ure itself. 

(£)  Interpretation.  A  positive  reaction  occurs  at  some  period  in 
the  course  of  ninety-five  per  cent  of  all  cases  of  typhoid  fever,  but 
the  proportion  of  cases  in  which  the  reaction  occurs  early  enough  to 
be  of  diagnostic  value  varies  greatly  in  different  epidemics.  In 
most  epidemics  about  two-thirds  of  the  cases  show  a  positive  Widal 
reaction  by  the  time  the  patient  is  sick  enough  to  consult  a  physi- 
cian. The  reaction  may  be  absent  one  day  and  present  on  the  next, 
and  varies  greatly  in  intensity  in  different  cases  and  at  different 
times  with  the  same  case. 

VI.  Blood  Parasites. 
1.   The  Malarial  Parasite  (see  Plates  IV.  and  V.). 

In  films  stained  as  above  directed  the  malarial  parasite  appears 
blue  against  the  pink  background  of  the  corpuscle.  A  crimson- 
stained  dot  should  appear  in  some  portion  of  the  blue-stained  or- 
ganism; the  protoplasm  of  the  red  corpuscle  around  it  is  often 
studded  with  pink  dots. 

The  stained  specimen  is  preferable  to  the  fresh  blood  in  the 
search  for  malarial  parasites,  for  the  young,  ring-shaped,  or  "hya- 
line" forms  often  escape  notice  altogether  in  fresh  specimens. 

Tertian  organisms  are  distinguished  from  the  aestivo-autumnal 
variety  by  the  following  tests : 

(a)  Tertian  parasites  make  the  corpuscle  containing  them  larger 
than  its  uninfected  neighbors. 

(i)  Segmenting  forms  never  occur  in  the  peripheral  blood  of  aes- 
tiro-autumnal  fevers. 

(c)  "Crescents"  (see  Plate  V.)  never  occur  except  in  aestivo- 
autumnal  fevers. 


CABOT- PHYSICAL    DIAGNOSIS. 


PLATE    IV. 


FIG.  I.— Young  Tertian  Parasites.    (Stained  with  Wright's  modiflcation  of 
Irishman's  stain.) 


Fio.  2.— Mature  Tertian  Parasites.    (Eosin  and  methylene  blue.) 


^ 


M 


FIG.  3.— Segmenting  Tertian  Parasites.     (Eosin  and  methylene  blue.) 


THE  BLOOD. 


485 


2.    The  Trypanosoma. 

In  Central  Africa  (and  presumably  in  other  tropical  countries) 
the  blood  or  gland  juice  of  many  persons  contains  the  organism 
shown  in  Fig.  217,  which  has  long  been  known  as  a  parasite  of  the 
blood  of  horses  and  of  many  of  the  lower  animals.  Human  try- 


Fio.  217.— Trypanosoma  in  Human  Blood.     (By  permission  of  Dr.  J.  Everett  Dutton  and  the 

London  Lancet.) 


paiiosomiasis — a  chronic,  debilitating  malady — becomes  "  sleeping 
sickness  "  when  the  trypanosoma  enters  the  cerebrospinal  canal. 

3.   Filariasis. 

In  the  blood  of  many  inhabitants  of  tropical  countries  there  is 
found  (with  or  without  symptoms)  the  parasite  shown  in  Fig.  218. 
The  species  most  often  found  is  present  in  the  peripheral  blood  only 


486  PHYSICAL  DIAGNOSIS. 

at  night;   hence  the  blood  should  be  examined  after  8  P.M.     A  fresh 


FIG.  2;8.— The  Filaria  Sanguinis  Hominis.    The  head,  curled  up,  is  seen  to  the  right  of  the  cut, 
the  tail  at  the  left.    Instantaneous  photomicrograph.    Four  hundred  diameters  magnification. 

drop  is  spread  between  slide  and  cover  and  examined  with  a  low- 
power  lens  (No.  5  objective  Leitz). 


FIG.  219.— Pratt's  Modification  of  the  Brodie-Russell  Coagulometer.  /{,  Brass  ring  soldered  to 
glass  slide ;  O,  cover  glass ;  a  blood  drop  on  the  under  side  of  this,  when  in  place  on  the  brass 
ring,  is  close  to  the  point  of  the  hollow  metal  needle  which  forms  the  extremity  of  the  infla- 
tion tube,  C. 


CABOT-PHYSICAL    DIAGNOSIS. 


PLATE    V. 


FIG.  1 .— Two  Young  ^Kstivo-autumnal  Parasites.     (Wright's  modification  of 
Irishman's  stain.) 


- 


FIG.  2.— JJstivo-autunrinal  Parasites.    Ring  body  at  the  left ;  orescent  at  the  right. 
Stained  like  Fig.  I. 


FIG.  3.— Ovoid  in  ^Estivo- 
autuinnal  Malaria. 


FIG.  4.— Crescent  in  ^stivo-autumnal  Malaria. 


THE  BLOOD.  487 


VII.   Estimation  of  Coagulation  Time,. 

The  Brodie-Russell  instrument,  as  modified  by  Pratt '  (see  Fig. 
219),  is  the  one  which  I  have  used  most.  To  use  the  instrument, 
we  put  a  drop  of  water  on  the  slide,  inside  the  metal  ring  (K). 
Smear  this  ring  with  vaseline.  Put  a  drop  of  blood  on  the  under 
side  of  the  cover  glass  and  press  the  latter  down  into  the  vaseline, 
so  that  the  blood  drop  comes  in  the  middle  of  the  metal  ring.  Then 
watch  it  with  a  low  power  of  the  microscope;  at  intervals  of  one 
minute  a  current  of  air  is  brought  into  contact  witli  the  drop  by 
means  of  a  rubber  tube  and  bulb,  C.  As  soon  as  coagulation  has 
taken  place,  the  impact  of  this  current  of  air  ceases  to  make  the 
corpuscles  fly  ahead  and  produces  a  radial  current. 

Normally,  coagulation  occurs  under  these  conditions  in  from 
three  to  eight  minutes;  anything  outside  these  limits  is  to  be  con- 
sidered pathological.  All  readings  must  be  made  at  a  single 
temperature. 

The  estimation  of  coagulation  time  seems  to  be  of  some  value  to 
surgeons  in  relation  to  the  question  of  operation'  in  cases  of  hem- 
orrhagic  tendency  (purpura,  jaundice,  and  various  liver  diseases). 

1  Pratt:  Journal  of  Medical  Research,  November,  1903.  The  instrument 
costs  75  cents. 


CHAPTER   XXIV. 

THE   JOINTS. 
EXAMINATIONS  OF  THE  JOINTS. 

A.  Methods  and  Data. 

I.  By  inspection  and  palpation  we  detect : 

1.  Pain,  tenderness,  and  heat  in,  near,  or  at  a  distance  from  the 
joint. 

2.  Enlargement: 

(a)  Hard,  probably  bony. 

(&)  Boggy,   probably  infiltration  or  thickening  of  capsule  and 
periarticular  structures. 

(c)  Fluctuating,  probably  fluid  in  the  joint. 

3.  Irregularities  in  contour : 

(a)  Osteophytes  or  "lipping"  (attached  to  the  bone). 
(6)  Gouty  tophi  (not  attached  to  the  bone). 

(c)  Constriction-line  opposite  the  articulation. 

(d)  Protrusion  of  joint-pockets  in  large  effusions,  filling  out  of 
natural  depressions. 

4.  Limitation  of  motion : 
(a)  Due  to  pain  and  effusion. 
(&)  Due  to  muscular  spasm. 

(c)  Due  to  thickening  or  adhesions  in  the  capsular  and  periartic- 
ular structures. 

(rf)  Due  to  obstruction  by  bony  outgrowths  or  gouty  tophi 

(e)  Due  to  ankylosis. 

5.  Excess  of  motion  (subluxation). 


THE  JOINTS.  489 

6.  Crepitus  and  creaking. 

7.  Free  bodies  in  the  joint. 

8.  Trophic  lesions  over  or  near  a  joint  (cold,  sweaty,  mottled, 
cyanosed,  white,  or  glossy  skin,  muscular  atrophy). 

9.  Sinus  formation,  the  sinus  leading  to  necrosed  bone,  to  gout}7 
tophi,  or  abscess  in  or  near  the  joint. 

10.  Distortion  and  malposition,  due  to  contractures  in  the  mus- 
cles near  the  joint,  to  necrosis,  to  exudation,  or  to  subluxation. 

11.  Telescoping  of  the  joint  with  shortening  (limb,  toe,  finger, 
or  trunk). 

II.  By  radioscopy  we  investigate : 

1.  Bony  outgrowths,  their  shape,  extent,  and  position. 

2.  Necroses  and  atrophies  of  bone,  their  extent  and  position. 

3.  The  structure  of  the  bones  in  and  near  the  joints. 

4.  The  presence  of  lesions  in  the  articular  cartilages. 

5.  Free  joint  bodies,  their  presence  and  position. 

III.  Indirectly  we  may  gain  valuable    information  about  the 
joints  by  noting: 

1.  General  constitutional  symptoms,  their  presence  or  absence. 
These  include  fever,  chills,  leucocytosis,  glandular  enlargement, 
albuminuria,  and  emaciation. 

2.  Tuberculin  reaction,  its  presence  or  absence. 

3.  Disease  of  other  organs,  their  presence  or  absence,  i.e.,  syph- 
ilis, tuberculosis,  tabes,  and  other  chronic  spinal-cord  lesions,  en- 
docarditis, haemophilia,  various  acute  infections  (gonorrhosa,  influ- 
enza, scarlatina,  septicaemia),  and  skin  lesions  (psoriasis,  purpura, 
hives). 

4.  The  course  of  the  disease  and  the  results  of  treatment. 

B.    Technique  of  Joint  Examination. 

(a)  Enlargement  is  generally  unmistakable,  but  when  there,  is 
much  muscular  atrophy  between  the  joints  the  latter  may  seem  en- 
larged by  contrast,  when  in  fact  they  are  not. 

(b~)  Fluctuation  is  obtained  in  most  joints,  as  in  any  part  of  the 
body,  by  pressing  a  finger  on  each  of  two  slightly  separated  spots 


490  %  PHYSICAL  DIAGNOSIS. 

in  the  suspected  area,  and  endeavoring  to  transmit  through  the  in- 
tervening space  an  impulse  from  one  finger  to  the  other.  Fat  or 
muscle  will  also  transmit  an  impulse,  but  less  perfectly  than  fluid. 

In  the  knee  we  test  for  "  floating  of  the  patella  "  over  an  effusion 
by  surrounding  the  joint  with  the  hands,  which  are  pressed  slightly 
toward  each  other  to  limit  the  escape  of  fluid  in  either  direction, 
and  then  suddenly  making  quick  pressure  on  the  patella  with  one 
ringer.  If  we  feel  or  hear  the  patella  knock  against  the  bone  below 
and  rebound  as  we  release  the  pressure,  fluid  in  abnormal  quantity 
is  present. 

(c)  Irregularities  of  contour  are  easily  recognized,  provided  the 
normal  contour  is  familiar. 

(cT)  Bony  outgrowths  may  be  obvious  (as  in  Heberden's  nodes), 
but  if  within  the  joint  they  may  be  recognized  only  by  the  sudden  - 
arrest  of  an  otherwise  free  joint  motion  at  a  certain  point.     In  many 
cases  radioscopy  is  necessary. 

(e)  Gouty  tophi  are  identified  positively  by  transf erring  a  minute 
piece  to  a  glass  slide,  teasing  it  in  a^  drop  of  water,  covering  with 
a  cover  glass,  and  examining  with  a  high-power  dry  lens  and  a 
partly  closed  diaphragm.     The  sodium  biurate  crystals  are  charac-   \ 
teristic. 

Fluid  or  semi-fluid  exudates  in  joints  may  fill  up  and  smooth  out 
the  natural  depressions  around  the  joint,  or,  if  the  exudate  is  large, 
may  bulge  the  joint  pockets;  in  the  knee-joint  four  eminences  may 
take  the  place  of  the  natural  depressions,  two  above  and  two  below 
the  patella. 

(y)  Limitations  of  motion  due  to  muscular  spasm  are  seen  with 
especial  frequency  in  tuberculous  joint  disease,  but  may  occur  in 
almost  any  form  of  joint  trouble,  particularly  in  the  larger  joints. 

(1)  Hip-joint,  two  forms  of  spasm  are  important:  (1)  That 
which  is  due  to  irritation  of  the  psoas  alone  (psoas  sp«sm);  (2)  that 
in -which  all  the  muscles  moving  the  joint  are  more  or  less  con- 
tracted. 

In  pure  psoas  spasm  the  thigh  is  usually  somewhat  flexed  on  the 
trunk,  though  this  maj7  be  concealed  by  forward  bending  of  the  lat- 
ter. Very  slight  degrees  of  psoas  spasm  may  be  appreciable  only 


THE  JOINTS.  491 

when,  with  the  patient  lying  on  his  face,  we  attempt  hyperexten- 
sion  (see  Fig.  220). 

The  other  motions  of  the  hip — rotation,  adduction,  abduction, 
and  flexion — are  not  impeded. 

General  spasm  of  the  hip  muscles  is  tested  with  the  patient  on 
the  back  upon  a  table  or  bed  (a  child  may  be  tested  on  its  mother's 


FHJ.  230.— Testing  for  Psoas  Spasm.    (Bradford  aud  Lovett.) 

lap)  and  the  leg  flexed  to  a  right  angle,  both  at  the  knee  and  at  the 
hip.  Using  the  sound  leg  as  a  standard  of  comparison,  we  may 
then  draw  the  knee  away  from  the  middle  line  (abduction),  toward 
and  past  the  middle  line  (adduction),  and  toward  the  patient's 
chest  (flexion).  Rotation  is  tested  by  holding  the  knee  still  and 
moving  the  foot  away  from  the  median  line  of  the  body  or  toward 
and  across  it 

(2)  Spinal  column.  Muscular  spasm  of  the  muscles  guarding 
motion  in  the  vertebral  joints  can  be  tested  by  watching  the  body 
attitude  (a  stiff,  "military"  carriage  in  most  cases),  and  by  efforts 
to  bend  the  spine  forward,  backward,  and  to  the  sides. 

In  most  cases  we  can  make  out  limitation  of  these  motions  by 
asking  the  patient  to  stand  with  knees  and  hips  stiff  and  then  bend 
his  trunk  (of  course,  naked)  as  far  as  he  can  in  each  of  the  four 
directions.  If  we  are  familiar  with  the  average  range  of  motility 


492  PHYSICAL  DIAGNOSIS. 

in  each  direction  and  at  the  different  ages,  this  test  is  usually  easy 
and  vapid.  Backward  bending  is  the  least  satisfactory,  and  in 
doubtful  cases  the  patient  should  be  on  his  face,  while  the  physi- 
cian, standing  above  him,  lifts  the  whole  body  by  the  feet  (see  Fig. 
221). 

(3)  In  the  joints  of  the  shoulder,  knee,  elbow,  wrist,  ankle, 
toes,  and  fingers,  there  is  usually  no  difficulty  in  testing  for  muscu- 
lar spasm,  and  no  special  directions  are  needed. 

To  distinguish  muscular  spasm  from  bony  outgrowth  as  a  cause  of 
limited  joint  motion,  we  should  notice  that  bony  outgrowths  (e.g., 


FIG.  221.— Rigidity  of  Spine  in  Pott's  Disease. 

in  the  hip)  allow  perfectly  free  motion  up  to  a  certain  point ;  then 
motion  is  arrested  suddenly,  completely,  and  without  great  pain. 
Muscular  spasm,  on  the  contrary,  checks  motion  a  little  from  the 
outset,  the  resistance  and  pain  gradually  increasing  until  our  efforts 
are  arrested  at  some  point,  vaguely  determined  by  our  strength  and 
hard-heartedness  and  by  the  patient's  ability  to  bear  the  pain. 

Motions  limited  by  capsular  thickening  and  adhesions  are  not, 
as  a  rule,  so  painful  after  the  first  limbering-up  process  is  over. 
There  is  no  sudden  arrest  after  a  space  of  free  mobility,  but  motion 


THE  JOINTS.  493 

is  limited  from  the  first  and  usually  in  all  directions,  though  the 
muscles  around  the  joint  are  not  rigid.  The  possibility  of  more  or 
less  limbering-out  after  active  exercise  (or  passive  motion)  distin- 
guishes this  type  of  limitation. 

In  true  ankylosis,  there  is  no  motility  whatever. 

(//)  Excessive  motion  in  a  joint  is  recognized  simply  by  contrast 
with  the  limits  furnished  us  by  our  knowledge  of  anatomy  and  of 
the  physiology  of  joint  motion  at  different  ages.  When  the  bone 
and  cartilage  appear  normal  or  are  not  grossly  injured,  we  call  the 
excessive  motility  of  the  joint  a  sitbluxation,  but  excessive  motility 
may  also  be  due  (as  in  Charcot's  joint)  to  destruction  of  bone  and 
other  essentials  of  the  joint. 

(7i)  To  detect  crepitus  and  creaking  we  simply  rest  one  hand  on 
the  suspected  joint,  and  with  the  other  put  it  through  its  normal 
motions,  while  the  patient  remains  passive. 

(*)  Most  free  joint  bodies  are  not  palpable  externally,  and  are  rec- 
ognized only  by  their  symptoms,  by  the  ce-ray,  and  by  operation. 

(,/)  Shortening  of  a  limb  as  evidence  of  joint  lesions  is  tested  by 
careful  measurements.  The  vast  majority  of  such  measurements 
are  made  with  reference  to  the  hip-joint.  The  tip  of  each  anterior 
superior  iliac  spine  is  marked  with  a  skin-pencil,  and  likewise  the 
tip  of  each  inner  malleolus.  Then,  with  the  patient  lying  at  full 
length  on  a  flat  table,  the  distance  from  anterior  superior  spine  to 
inner  malleolus  is  measured  with  a  tape  on  each  side. 

The  method  of  obtaining  the  other  data  tabulated  on  page  488 
needs  no  explanation,  except  the  radioscopic  technique — a  subject 
which  I  am  not  competent  to  discuss. 


C.  Joint  Diseases. 

I  shall  use  the  classification  proposed  by  Goldthwaite  and  divide 
joint  diseases  as  follows  : 

1.  Infectious  arthritis :  («)  Tuberculosis.     (&)  Other  infections. 

2.  Atrophic  arthritis :  («)  Primary,     (b)  Secondary  to  organic 
nerve  lesions  (Charcot's  joint). 


494  PHYSICAL  DIAGNOSIS. 

3.  Hypertrophic  arthritis. 

4.  Gouty  arthritis. 

5.  Haemophilic  arthritis. 

Under  infectious  arthritis  are  included  all  varieties  of  articular 
"rheumatism  "  and  the  joint  troubles  symptomatic  of  gonorrhoea,  of 
streptococcus  infections  (including  scarlet  fever),  influenza,  syphi- 
lis, typhoid,  and  other  fevers.  As  tuberculosis  is  an  infection  we 
must  include  it  in  this  group,  although  the  disease  begins  usually 
as  an  osteitis  and  involves  the  joint  secondarily  by  extension. 

I.  Tuberculous  Arthritis. — The  characteristics  of  joint  tubercu- 
losis are : 

(a)  Slow  progress,  with  gradual  enlargement  and  disabling  of  the 
joint. 

(b)  Muscular  spasm,  especially  in  disease  of  the  hip  or  vertebrae. 

(c)  Evidences  of  low-grade  inflammation  (moderate  heat,  swell- 
ing, pain,  and  tenderness). 

(cC)  Abscess  and  sinus  formation. 

(e)  Malpositions  (e.g.,  shortening  of  one  leg  in  hip-joint  disease, 
angular  backward  projection  in  spinal  disease,  subluxations  in  the 
knee-joint). 

(/)  Bone  necrosis,  as  shown  by  x-ray. 

The  order  of  frequency  in  the  different  joints  is  as  follows: 
spine,. hip,  knee,  wrist,  shoulder  (tuberculous  dactylitis  is  described 
on  page  50). 

In  the  deep-seated  hip-joint,  diagnosis  has  to  depend  largely  on 
shortening  and  on  the  presence  of  limitation  of  all  the  hip  motions 
by  muscular  spasm  (see  above,  page  491),  unless  the  disease  is  of 
long  standing  and  manifests  itself  by  abscesses  burrowing  to  the 
surface.  Usually  these  abscesses  point  in  the  upper  anterior  thigh, 
but  they  may  open  behind  the  great  trochanter,  below  the  glutens 
maxiinus,  or  at  any  point  in  the  vicinity  of  the  hip. 

Besides  muscular  spasm,  shortening,  and  abscess  formation,  we 
get  some  aid  from  the  general  and  vague  joint  symptoms  present  in 
this  as  in  many  other  joint  lesions.  Such  are  enlargement  (felt  as 
thickening  about  the  great  trochanter),  muscular  atrophy,  pain,  ten- 
derness, and  crepitus. 


THE  JOINTS.  495 

In  spinal  tuberculosis  (Pott's  disease)  the  distortion  of  the  bones 
with  formation  of  a  knuckle  in  the  back  is  often  obvious  and  prac- 
tically diagnostic.  In  other  cases  we  depend  on  muscular  spasm  or 
abscess  formation.  The  muscular  spasm  gives  a  stiff  back  and  often 
psoas  contraction  (see  below).  The  abscess  is  peculiar,  in  that  it 
usually  Avorks  along  in  the  sheath  of  the  psoas  and  points  in  the 
groin  below  Poupart's ligament  (see  Fig.  202);  less  often  it  appears 
in  the  back  or  in  the  gluteal  region,  and  rarely  it  may  invade  almost 
any  part  of  the  body  (lung,  gullet,  gut,  peritoneum,  rectum,  hip- 
joint,  etc.). 

Psoas  spasm,  which  is  common  both  in  hip  and  spinal  tubercu- 
losis, is  by  no  means  peculiar  to  these  diseases,  and  it  is  worth  re- 
membering that  it  may  be  due  to  various  other  lesions,  such  as : 

(a)  Hypertrophic  arthritis  of  the  spine. 

(£)  Appendix  abscess. 

(c)  Perinephritic  abscess. 

In  the  peripheral  joints  (shoulder,  elbow,  wrist,  finger,  knee, 
ankle)  the  diagnosis  of  tuberculosis  rests  on  the  chronic  enlarge- 
ment and  disability,  with  abscess  and  sinus  formation. 

Hysterical  or  acute  traumatic  lesions  (with  or  Avithout  neurosis) 
may  present  symptoms  and  signs  identical  Avith  those  of  tubercu- 
losis. Decision  is  aided  most  by :  (a)  The  lapse  of  time  and  the  ef- 
fects of  treatment.  (&)  x-Kay  examination,  (c)  The  predominance 
in  functional  and  traumatic  cases  of  pain  and  tenderness  rather  than 
muscular  spasm  or  malposition. 

II.  Acute  Infectious  Arthritis. — All  varieties  are  distinguished 
from  the  other  types  of  arthritis  by :  (a)  The  absence  of  any  marked 
bone  lesions  1  inmost  cases.  (£)  The  tendency  to  recovery  in  the  great 
majority  of  cases. 

The  milder  forms,  Avhose  cause  is  unknown,  we  have  hitherto 
designated  as  "rheumatism."  The  others  are  distinguished  as 
gonorrhoeal,  pneumococcic,  syphilitic,  influenzal,  dysenteric,  etc., 
according  to  the  organism  producing  them. 

Between  this  group  and  those  knoAvn  as  "rheumatism,"  there  is 

1  Exceptionally,  virulent  infectious  (especially  those  due  to  pneumococci  or 
streptococci)  may  destroy  cartilage  and  bone  and  end  in  true  bony  ankylosis. 


496 


PHYSICAL  DIAGNOSIS. 


FIG.  222.-#-Ray,  showing  Hands  In  Atrophic  Arthritis. 


THE  JOINTS. 


497 


no  clear  pathologic  distinction.  Mild  infection  with  pyogenic  cocci 
may  leave  a  sound  joint,  though  the  general  tendency  is  to  crippling 
through  fibrous  adhesions.  On  the  other  hand,  arthritis  of  "  rheu- 
matic" {i.e.,  of  unknown)  origin  may  end  in  suppuration,  crippling 
the  joint  with  adhesions,  though  in  most  cases  it  leaves  a  sound 
joint. 

All  the  members  of  the  infectious  group  of  joint  lesions  present 
the  local  signs  of  inflammation  and  the  constitutional-  signs  of  infec- 


a  b 

FIG.  223.— a,  Charcot's  Joint  with  Loose  Bodies ;  h.  Pulmonary  Osteo-arthropathy. 

tion.  All  may  be  complicated  by  endocarditis,  but  in  those  of  un- 
known origin  ("  rheumatic  ")  this  complication  is  especially  com- 
mon. There  is  no  bony  hypertrophy,  bone  destruction,1  sinus 
formation,  or  marked  irregularities  of  contour.  A  general  enlarge- 
ment (more  or  less  spindle  shaped,  owing  to  periarticular  thick- 
ening and  muscular  atrophy)  is  the  rule.  The  joint  motions  are 

1  See  note  on  page  495. 
32 


498  PHYSICAL  DIAGNOSIS. 

limited  chiefly  by  pain  and  effusion;  muscular  spasm  is  not  prom- 
inent. 

One  or  many  large  or  small  joints  may  be  affected  in  any  of  the 
varieties  of  infectious  arthritis,  though  the  gonorrhoeal  virus  is  "apt 


FIG.  224.— Atrophic  Arthritis.    Early  stage. 

to  lodge  in  few  joints  (oftenest  the  knee  or  ankle)  and  the  "  rheu- 
matic "  virus  in  many  joints,  while  the  typhoid  poison  has  a  predi- 
lection for  the  spine. 

III.  Atrophic  Arthritis. — Two  types  must  be  recognized:  (a)  A 
monarticular  form,  secondary  usually  to  tabes  or  syringomyelia 
("Charcot's  joint,"  " neuropathic  joint"),  and  other  diseases  of  the 
spinal  cord.  (//)  A  poly  articular  primary  form  ("rheumatoid  ar- 
thritis"). 

In  both,  the  distinguishing  characteristic  is  atrophy  and  destruc- 
tion of  cartilage,  bone,  and  joint  membranes — a  process  which  in 
the  early  stages  can  be  identified  only  by  the  cc-ray  (see  Fig.  222). 


THE  JOINTS. 


499 


Later  the  disintegration  of  the  joint  is  usually  evident,  and  is  fol- 
lowed by  distortions,  eontractures,  and  ankylosis. 

(a)  The  monarticular  form  is  generally  easy  to  recognize  on  ac- 
count of  its  rapid,  painless  course,  with  sernifluctuant  swelling, 
secondary  to  a  well-marked  cord  lesion,  such  as  locomotor  ataxia. 
A  large  joint  is  almost  always  affected,  oftenest  the  knee,  less  often 
the  hip,  shoulder,  or  elbo\v. 
The  joint  shows  abnormal 
mobility  and  the  bones  can 
often  be  felt  to  grate  (see  Fig. 
223). 

(//)  The  prinidrij  [Kilij artic- 
ular form  usually  begins  in 
the  fingers,  and  is  very  apt  to 
occur  symmetrically,  i.e.,  in 
corresponding  joints  of  both 
hands  at  the  same  time  (see 
Fig.  224) .  The  joints  are  en- 
larged, boggy,  spindle  shaped 
(owing  to  the  rapid  atrophy 
of  the  interossei),  often  abnor- 
mally white,  apparently  fluct- 
uant, and  show  trophic  skin 
lesions  (glossy  skin,  sweat- 
ing, mottling)  (see  Fig.  225). 
The  terminal  finger-joints  are 
rarely  swollen.  Late  in  the 
course  of  the  disease  a  ring  of  constriction  often  marks  the  line  of 
articulation  (see  Fig.  226).  Fain  is  not  severe  until  motion  is  at- 
tempted or  unless  the  joint  is  jarred  and  stirred  up  by  some  trau- 
matism. 

The  changes  progress  slowly  and  attack  new  and  larger  joints, 
moving  centrally  from  the  periphery.  At  any  stage  the  process 
may  become  arrested,  but  usually  not  until  ankylosis  or  contractures 
have  occurred  in  one  or  many  joints.  Some  of  the  "ossified  men" 
of  dime  museums  are  in  the  ankylosed  stage  of  this  terrible  malady. 


FIG.  225.--Atrophic  Arthritis.     (Uoldthwaite.) 


500  PHYSICAL  DIAGNOSIS. 

Flexion  of  fingers  with  hyperextension  of  the  terminal  joints  and 
deflection  to  the  ulnar  side  are  common  deformities. 

IV.  Hypertrophic  Arthritis. — Bony  enlargement  and  osteophytic 
spurs  are  the  distinguishing  feature.  The  new  bone  is  oftenest  de- 
posited round  the  edges  of  the  articular  cartilage,  forming  an  irreg- 
ular fungoid  ring  ("ring  bone"  in  horses)  or  "lip"  near  the  joint. 


FIG.  226.— Atrophic  Arthritis.    Late  stage  with  constriction  ring  at  the  joint  line.   (Goldthwaite.) 

The  attachments  of  the  ligaments  (e.g.,  the  anterior  lateral  liga- 
ment of  the  spine  or  the  cotyloid  ligament  in  the  hip-joint)  furnish 
another  favorite  site  for  the  bony  deposits. 

(a)  In  the  terminal  finger-joints  ( " Heberden's  nodes")  the 
process  may  remain  for  years  without  extending  to  any  other 
articulation  and  without  producing  any  discomfort  (Figs.  50  and 
227). 

(i)  The  disease  may  be  limited  to  the  hip-joint  ("morbus  coxae 
senilis  ")  or  to  any  other  single  joint,  producing  purely  mechanical 
disturbances  by  limitation  of  motion.  There  is  no  considerable 
muscular  spasm,  and  motion  is  quite  free  up  to  a  certain  point,  at 


THE  JOINTS. 


501 


which  it  is  suddenly  "  locked  "  by  the  interference  of  the  bony  out- 
growths. The  situation,  size,  and  shape  of  these  outgrowths  can  be 
shown,  as  a  rule,  by  the  ar-ray  alone.  Pain  and  swelling  are 
slight  or  absent,  unless  traumatism  (internal  or  external)  stirs 


FIG.  227. — Hypertropbic  Arthritis  with  Heberdeii's  Nodes. 

up  the  joint  and  produces  a  synovitis.     The  chief  complaint  is  of 
stiffness. 

(c)  Several  joints  may  be  affected,  and  there  may  result  much 
pain  because  nerves  pass  through  or  over  the  new-formed  bone  and 
are  compressed  by  it.  This  form  is  most  often  seen  in  the  spine 
("  spondylitis  deforinans,"  "  osteoarthritis  "),  where  a  portion  of  the 
front  and  side  of  the  vertebral  column  is  "plastered  over"  with 
new-formed  bone  (see  Fig.  228),  which  later  invades  the  iuterverte- 


502 


PHYSICAL  DIAGNOSIS. 


bral  cartilage  and  produces  ankylosis  (see  Fig.  229) ,  either  a  straight 
"ramrod"  spine  or  a  forward  curved  spine. 


FIG.  228.— Uypertrophlc  Arthritis  of  Spine.    (Goldthwaite.) 


THE  JOINTS.  50.3 

In  the  early  stages  the  disease  is  recognized  by : 

(a)  Nerve  pain,  running  round  the  body  or  down  the  legs,'  as 

the  intercostal  and  spinal  nerves  are  pressed  on. 

(^)  Limitation  of  Motion.     The  process  is  usually  unilateral, 

wholly  or  predominantly;   hence  the  patient  can  usually  bend  much 


FIG.  229.— Hypertrophic  Arthritis  (Spine)  of  Spine  with  Ankylosis.     (Goldthwaite.) 

better  to  one  side  (see  Figs.  220  and  231)  than  to  the  other.  Mo- 
tion is  also  more  or  less  limited  in  other  directions,  but  forward 
bending  is  fairly  well  performed  as  a  rule,  in  sharp  contrast  with 
"  lumbago,"  which  renders  forward  bending  and  the  subsequent  re- 
covery almost  impossible. 

(c)  Coughing  or  sneezing  often  gives  great  pain,  probably  because 
the  costo- vertebral  joints  are  involved  in  the  new  growth;  if  aiiky- 
losis  of  these  joints  occurs  later,  the  respiratory  movements  of  the 
chest  are  interfered  with. 

V.  Gouty  Arthritis. — The  deposits  of  urate  of  sodium  in  the 
soft  structures  around  the  joint  are,  like  those  in  the  ear  (see 

1  Many  neuralgias  and  sciaticas  are  due  to  this  disease. 


504 


PHYSICAL  DIAGNOSIS. 


FIG.  230.— Showing  Normal  Flexibility  of  Spine.    (Goldthwaite.) 


FIG.  231.— Hypertrophic  Arthritis  of  Spine.    Motion  to  left  limited.    (Goldthwaite.) 


THE  JOINTS. 


505 


Fig.  232),  close  beneath  the  skrn  or  perforate  it,   and  hence  are 
recognizable  (as  above  explained)  by  microscopic  examination. 

They  somewhat  resemble  the  nodes  of  hypertrophic  arthritis, 
but  are  not  attached  to  the  bone  and  can  be  moved  about  in  the  soft 
structures  over  it.     x-Kay 
examination     shows     that 
there  is  often  considerable 
destruction  of  bone  in  the 
vicinity  of  the  tophi    (see 
Figs.  233  and  234). 

VI.     HcKmopli'U  li-      Ar- 


FIG.  232.— Gouty  Tophus  in  the 
Ear. 


FIG.  233.  -  Gouty  Arthritis.     (Goldthwaite.) 


thritis. — A  chronic  stiffening  and  enlargement  of  the  joint,  re- 
sembling in  many  respects  the  joint  of  hypertrophic  arthritis, 
but  often  accompanied  by  the  formation  of  fibrous  adhesions,  en- 
sues in  some  cases  of  haemophilia,  presumably  as  a  result  of  fre- 
quent hemorrhages  and  serous  oozings  in  the  joint.  The  diagnosis 
depends  on  the  evidence  of  haemophilia,  the  youth  of  the  patient, 
and  the  absence  of  infection  as  a  causative  factor. 


o06 


PHYSICAL  DIAGNOSIS. 


RELATIVK  FREQUENCY  OF  THE  VARIOUS  JOINT  Licsioxs.1 — The 
following  table  was  prepared  by  Dr.  Vickery  '  from  the  records  of 


FIG.  2^4.    r-Ilay  of  Hand  in  (Jouty  Arthritis.     (Goldtlnvaite.) 


the  Massachusetts  General  Hospital  (1893-1903)  : 

f  Acute  rheumatic  arthritis 591  | 

T  ,    ,  iv      Subacute  rheumatic  arthritis 193  !  e_Q 

Infectious  arthritis  <-  ,,  >873 

Gonorrhoeal  arthritis 8b 

(^Typhoid  artliriiis  (sipine) 3j 

Hypertrophic  and  atrophic  arthritis 43 

Gout 9 

1  Chronic  villous  arthritis  ("dry  joint  ")  is  a  purely  local  process  and  there 
fore  receives  no  further  mention  here. 

"Boston  Med.  and  Surg.  Jour.,  November  17th,  1904. 


CHAPTER   XXV. 

THE   NERVOUS    SYSTEM. 
EXAMINATION  OF  THE  NERVOUS  SYSTEM. 

THE  outlines  of  neurological  diagnosis  depend  on  knowledge  of: 

I.  Disturbances  of  motion. 

II.  Disturbances  of  sensation. 

III.  Disturbances  of  reflexes  (including  sphincteric  and  sexual 
reflexes). 

IV.  Disturbances  of  electrical  excitability. 

V.  Disturbances  of  speech  and  handwriting. 

VI.  Disturbances  of  nutrition  ("trophic"). 

VII.  Psychic  disorders. 

I  shall  attempt  no  topical  diagnosis  of  nerve  lesions,  no  diag- 
nosis, that  is,  depending  on  memorizing  the  brain  areas,  cord  lev- 
els, or  skin-and-muscle  areas  corresponding  to  particular  nerve 
lesions.  The  general  practitioner  for  whom  this  book  is  intended 
will  not  attempt  to  carry  such  points  in  his  head,  but  will  refer  to 
specialists  or  special  text-books  when  the  case  confronts  him.  The 
general  methods  most  often  employed  are  all  that  I  attempt  to  de- 
scribe. 

/.   Disorders  of  Motion. 

1.  Gaits. 

2.  Paralyses. 

3.  Spasms  and  tremors. 

4.  Ataxia. 

1.   Gaits. — The  most  important  gaits  are: 
(a)  The  spustic. 
(i)  The  ataxic. 


508  PHYSICAL  DIAGNOSIS. 

(c)  The  gait  of  paralysis,  agitans. 

(d)  The  toe-drop  gait. 

(e)  The  gait  of  simple  weakness. 

With  the  spastic  gait  there  is  rigidity  of  the  legs,  making  it 
difficult  to  lift  the  feet ;  hence  the  patient  scuffs  along,  usually  with 
bent  knees  and'as  if  his  feet  were  fastened  to  the  ground.1 

The  ataxic  gait  is  difficult  to  describe.  The  patient  is  not  raus- 
cularly  weak,  but  does  not  know  where  his  feet  are  or  where  the 
ground  is;  hence  he  flounders  and  throws  his  feet  about  irregularly. 

The  gait  of  paralysis  agitans  is  an  exaggeration  of  the  old  man's 
gait,  sucli  as  we  often  see  on  the  stage.  The  whole  body  is  bent 
forward  and  rigid  (see  Fig.  235),  and,  if  progress  is  accelerated  by 
a  push  given  from  behind,  the  patient  may  be  unable  to  stop  himself. 

In  the  toe-drop  gait  the  foot  is  raised  high  and  slapped  down 
upon  the  ground  with  a  flail-like  motion. 

2.  Paralysis  or  Paresis. — No  detailed  account  can  be  given  here 
of  the  method  of  testing  individual  muscles  for  loss  or  impairment 
of  power.  In  general,  a  knowledge  of  the  origins  and  attachments 
of  muscles  enables  us  to  work  out  for  ourselves  a  series  of  tests 
that  will  bring  any  desired  group  into  contraction.  It  is  convenient 
to  class  paralyses  according  to  their  origin  as  follows : 

(«)  Brain  paralysis :  usually  hemiplegia  (arm  and  leg  on  same 
side,  with  or  without  the  face). 

(&)  Cord  paralysis :  usually  paraplegia  (both  legs,  rarely  both 
arms)  or  monoplegia  (one  extremity). 

(c)  Cranial  nerve  paralysis :  usually  one  or  more  eye  muscles. 

(d)  Peripheral  nerve  paralysis  :    sjjecial  muscle  groups,  oftenest 
the  extensors  of  the  wrist  or  foot,  the-  shoulder  muscles,  and  those 
supplied  by  the  facial  nerve. 

(e)  Hysterical  paralysis :    no  strict  anatomical  distribution,  of- 
tenest monoplegia  (one  extremity). 

Peripheral  nerve  paralyses  are  especially  apt  to  be  accompanied 
by  sensory  symptoms,  electrical  changes,  and  wasting.  Brain  paral- 

1  The  cross-legged  gait  is  a  spastic  gait  in  which  the  adductors  of  the  thighs 
are  so  contracted  that  the  feet  tend  to  be  crossed.  This  gait  is  oftenest  seen 
in  the  congenital  spastic  paralyses. 


THE  NERVOUS  SYSTEM. 


509 


yses  have  relatively  few  sensory  symptoms  (sometimes  parsesthe- 
sise,  see  below,  page  512)  and  relatively  slight  wasting.  Mental 
changes,  coma,  or  convulsions  often  precede  or  follow  them.  Cord 


FIG.  235.— Attitude  Characteristic  of  Paralysis  Agitans.    (Curschmann.) 

paralyses  may  or  may  not  show  these  associations,  but  are  often 
accompanied  by  disorders  of  the  bladder  and  rectum. 

3.  Spasm,  Tremor,  and  Fibrillary  Twitching. — («)  Spasm  means 
involuntary  muscular  contraction.  The  familiar  "cramp  "  is  a  good 
example  of  the  type  of  spasm  known  as  tonic  spasm.  In  contrast 
with  this  is  the  cloniv  spasm,  in  which  flexors  and  extensors  con- 
tract alternately  to  produce  a  motion  like  that  of  our  forearm  when 


510  PHYSICAL  DIAGNOSIS. 

we  shake  up  a  fluid  in  a  test  tube,  or  like  the  ankle  clonus  (see 
below). 

Spasms  may  be  general  or  local,  i.e.,  involve  few  or  many  mus- 
cles. In  strychnine  poisoning  the  whole  body  may  be  thrown  into 
rigidity  or  general  tonic  spasm.  At  the  beginning  of  an  epileptic 
seizure  the  body  stiffens  out  (tonic  spasm),  then  becomes  "con- 
vulsed "  (general  clonie  spasni).  Local  tonic  spasm  is  exemplified  in 
the  ordinary  "cramp."  The  spastic  gait,  above  described,  is  an- 
other common  example  of  tonic  spasm  limited  mainly  to  one  group 
of  muscles.  The  contractures  which  so  often  affect  the  sound  mus- 
cles in  a  partially  paralyzed  limb  (see  above,  page  508)  are  also  ex- 
amples of  local  tonic  spasms. 

Athetosis,  a  special  variety  of  local  tonic  spasm,  has  been  de- 
scribed on  page  45. 

Local  clonie  spasm  is  not  common.  It  may  be  due  to  irritation 
of  a  small  portion  of  the  cerebral  cortex  by  various  lesions  ("  Jack- 
sonian  epilepsy  "),  and  sometimes  precedes  or  alternates  with  the 
general  spasms  of  ordinary  epilepsy.  It  also  occurs  in  hysteria. 

Artificially  a  momentary  or  prolonged  clonie  spasm  of  the  foot 
muscles  is  often  produced  in  testing  for  the  ankle  clonus  (see  below, 
page  515). 

(b)  Tremor  may  be  defined  as  a  clonie  spasm  of  short  excursion. 
Its  causes  and  varieties  have  already  been  discussed  (see  page  43). 

(c)  Fibrillary  twitchings  means  the  brief  repeated  contraction  of 
small  bundles  of  muscle  fibres.     It  is  seen  in  patients  who  are  cold 
or  nervous,  in  many  debilitated  and  neurasthenic  conditions,  and 
often  in  muscles  affected  by  progressive  muscular  atrophy. 

(d)  Choreic  and  choreiform  movements  have  already  been  de- 
scribed (page  44). 

4.  Ataxia. — Inco-ordination  of  the  various  muscles  which  nor- 
mally act  together  to  produce  a  well-directed  movement  is  called 
ataxia.  All  young  infants  exhibit  ataxia  in  their  more  or  less  un- 
successful grasping  movements.  Alcoholic  intoxication  often  pro- 
duces typical  ataxia,  and  it  is  also  exemplified  in  the  gait  of  tabes 
dorsalis.  There  is  no  lack  of  muscular  contraction — often  too  much 
— but  it  is  disorderly  and  ill-directed. 


THE  NERVOUS  SYSTEM.  511 

Deficiency  in  the  power  to  balance  in  standing  or  walking  is  per- 
haps the  commonest  type  of  ataxia,  and  may  be  due  not  only  to  the 
causes  just  mentioned,  but  also  to  cerebellar  disease  and  ear  dis- 
ease. In  these  types  there  is  often  a  tendency  to  stagger  in  one 
particular  direction,  e.g. ,  to  the  right,  and  the  ataxia  is  associated 
with  vertigo  and  with  other  evidences  of  brain  tumor  or  of  ear  dis- 
ease. 

In  tabes  dorsalis  and  other  diseases  we  test  the  power  to  bal- 
ance by  asking  the  patient  to  bring  his  feet  together  (toe  to  toe  and 
heel  to  heel)  and  to  close  his  eyes.  If  he  is  unable  to  preserve  his 
balance  his  failure  is  known  as  " Rombercfs  sign." 

11.  Disorders  of  Sensation. 

The  following  are  the  most  important  types : 

1.  Anesthesia  (or  insensibility  to  pain,  to  touch,  to  heat  and 
cold,  and  to  muscle  sensation). 

2.  Ifypercesthesia  (or  oversensitiveness'). 

3.  Parwsthesia  (abnormal,  false,  or  disordered  sensation). 

4.  Pain. 

5.  Disorders  of  special  sense. 

These  disturbances  may  all  be  seen  in  different  stages  or  types 
of  lesions  of  the  spinal  cord  or  peripheral  nerves.  They  are  less 
common  in  brain  lesions. 

1.  Tests  of  anaesthesia  are  time-consuming  and  difficult,  because 
we  depend  for  our  data  on  the  patient's  intelligent  answer  to  the 
question,  "Do  you  feel  that?"  As  a  rule,  we  cover  the  patient's 
eyes  and  then  touch  the  suspected  parts — first  lightly,  then  more 
strongly — questioning  him  to  see  if  he  feels  the  touch,  can  judge 
the  nature  of  the  touching  object  (finger,  pencil,  pin),  and  tell 
where  he  is  touched.  A  pin-prick  is  oftenest  used  to  test  pain 
sense,  and  test  tubes  filled,  one  with  hot,  one  with  cold  water,  are 
convenient  for  trying  the  temperature  sense.  Finally,  we  try 
whether  the  patient  can  recognize  familiar  objects  placed  in  his 
hand  and  can  tell  the  position  in  which  you  may  piit  his  arms  or 
legs.  Failure  to  make  these  discriminations  is  known  as  astereog- 


512  PHYSICAL  DIAGNOSIS. 

nosis,  and  occurs  oftenest  in  brain  lesions  affecting  the  temporal 
lobes. 

Dissociation  of  sensation — the  preservation,  for  example,  of 
sensations  of  touch  with  loss  of  those  of  pain  and  temperature  — 
occurs  oftenest  in  syringomyelia. 

Delayed  sensation  and  mistakes  regarding  the  point  touched  in 
testing  are  commonest  in  tabes  dorsalis,  which  disease  presents  a 
great  variety  of  sensory  disorders  not  here  catalogued. 

The  distribution  of  anaesthesia  depends,  like  the  distribution  of 
paralysis,  on  the  lesion.  Hemiancesthesia  is  seen  oftenest  in  hyste- 
ria and  organic  brain  lesions.  Cord  lesions,  such  as  transverse  mye- 
litis or  compression  of  the  cord,  usually  produce  anaesthesia  in  'the 
area  supplied  by  the  spinal  nerves  below  the  lesion.  Peripheral 
nerve  lesions  may  produce  anaesthesia  of  the  skin  areas  supplied  by 
the  nerve  in  question. 

Areas  of  hysterical  anaesthesia  (with  hyperaesthesia  and  paraes- 
thesia)  usually  do  not  correspond  to  the  distribution  of  any  set  of 
nerves  or  centres,  and  are  distinguished  by  this  fact. 

2.  Hypercesthesia  is  most  often  recognized  as  hypersesthesia  for 
pain  (tenderness)  or  in  the  special  senses  (sensitiveness  to  light  or 
noise).     It  is  commonest  in  peripheral  nerve  lesions  and  in  hyste- 
ria.    The  tests  are  the  same  as  those  for  anaesthesia. 

3.  Parcesthesia  is  commonest  in  the  form  of  the  familiar  prick- 
ling and  tingling  felt  when  one's  arm  or  leg  has  "gone  to  sleep." 
Sensations  as  of  crawling  insects  are  not  uncommon;  the  "  hot  feet " 
of  many  elderly  persons  (with  arteriosclerosis)  and  the  "burning 
hands  "  of  many  washerwomen  are  other  familiar  examples. 

Local parcesthesia  is  not  uncommon  in  lesions  of  the  cerebral 
cortex,  and  constitutes  the  preliminary  "aura"  with  which  many 
attacks  of  epilepsy  are  ushered  in.  Well-developed  tabes  dorsalis 
shows  many  curious  or  distressing  varieties  of  paraesthesia,  as  do 
many  other  varieties  of  peripheral  neuritis. 

///.  Reflexes. 

We  may  distinguish : 
1.   Pupil  reflexes. 


THE  NERVOUS  SYSTEM.  513 

2.  Deep  reflexes  (tendon  reflexes). 

3.  Superficial  reflexes  (skin  reflexes). 

4.  Sphincteric  reflexes. 

5.  Sexual  reflexes. 

1.  Pupil  reflexes  have  been  described  on  page  15. 

2.  Tendon  Reflexes. — Among  the  most  important  of  these  is  the 
knee-jerk  (quadriceps  tendon);    less  important  are  the  ankle-jerk 
(Achilles  tendon)  and  ankle  clonus,  the  wrist,  elbow,  and  jaw  re- 
flexes. 

To  test  the  knee-jerk  many  methods  are  used ;  the  following 
seems  to  me  the  best :  The  patient  sits  with  his  knees  flexed  at  a 
blunt  angle.  The  physician  lays  his  left  hand  on  the  front  of  the 
thigh  and  strikes  the  tendon  of  the  quadriceps,  just  below  the  pa- 
tella, with  the  finger  tips  of  the  right  hand  or  with  a  rubber  ham- 
mer. The  left  hand  feels  the  sudden  contraction  of  the  quadriceps 
whether  the  foot  jerks  or  not.  If  no  contraction  is  obtained  we 
should  try  what  is  known  as  " reenforcement  of  the  knee-jerk." 
The  essence  of  this  is  concentration  of  the  patient's  attention  on 
a  voluntary  muscular  contraction  in  another  part  of  the  body.  We 
may  accomplish  this  by  asking  the  patient  to  hook  the  fingers  of 
his  hands  together,  and  at  a  given  signal  to  give  a  quick  pull  upon 
them  and  then  let  go.  The  physician  gives  the  signal  (often 
the  word  "  now  ")  and  strikes  the  patella  tendon  at  the  same  mo- 
ment. 

The  knee-jerk  is  often  wanting  or  feeble  in  young  infants.  It 
varies  a  great  deal  in  persons  of  different  temperament;  in  high- 
strung  or  oversensitive  persons  and  in  the  Jewish  race  very  lively 
knee-jerks  are  often  seen  without  disease. 

Absence  of  knee-jerk  is  oftenest  found  in : 

(a)  Peripheral  neuritis  (alcoholic,  diphtheritic,  lead,  etc.). 

(#)  Tabes  dorsalis. 

(c)  Anterior  poliomyelitis  (on  the  paralyzed  side). 

(d)  In  the  deepest  coma  from  any  cause. 
(e}  In  complete  severing  of  the  spinal  cord. 
Given  a  case  without  knee-jerks : 

33 


514  PHYSICAL  DIAGNOSIS. 

Neuritis  is  suggested  by  the  history  and  etiology,  by  the  pres- 
ence of  marked  sensory  symptoms  (pain,  tenderness),  and  the  ab- 
sence of  symptoms  pointing  to  the  brain  or  cord. 

In  tabes  the  Argyll-Robertson  pupil,  the  disturbance  of  the 
sphincters  and  sexual  power,  the  "  lightning  pains  "  here  and  there, 
the  presence  of  Romberg's  symptom  (see  page  511),  and  later  the 
ataxic  gait  are  important  confirmatory  signs. 

Anterior  poliomyelitis  presents  a  flaccid  paralysis,  usually  of  one 
extremity,  coming  on  suddenly  in  a  young  child  and  wholly  with- 
out sensory  symptoms. 

Comatose  patients,  if  the  coma  is  due  to  cerebral  hemorrhage 
and  is  not  of  the  profoundest  type,  often  show  increased  knee-jerks 
on  the  paralyzed  side;  but  in  very  profound  unconsciousness  all 
reflexes  are  lost. 

Partial  destruction  of  the  cord  often  increases  the  reflexes,  but 
total  division  usually  abolishes  them. 

Increased  knee-jerk  is  found  in : 

(a)  Cerebral  paralyses  (infantile,  apoplectic,  dementia  paralytica, 
etc.). 

(6)  Spastic  paraplegia  and  the  ainyotrophic  forms  of  lateral 
sclerosis. 

(c)  Many  cord  lesions,  localized  above  the  lumbar  enlargement 
(transverse  or  pressure  myelitis). 

(d)  In  the  earliest  stages  of  peripheral  neuritis. 

(e)  Multiple  sclerosis. 

(/)  Some  forms  of  chronic  arthritis. 

DIFFERENTIAL  DIAGNOSIS  of  cases  with  increased  knee-jerks : 
Cereliral  paralyses  usually  manifest  their  place  of  origin  b}-  the 

presence  of  psychic   symptoms    (coma,  idiocy,  dementia)  and  by 

convulsions.     The  paralysis  is  usually  hemiplegic  and  involves  no 

wasting  beyond  the  atrophy  of  disuse. 

Spastic  paraplegia  is  readily  recognized  by  the  gait  (see  page 

508)  and  the  absence  of  marked  sensory  or  sphincteric  symptoms. 

Its  pathology  is  not  known.      If  marked  wasting  of  the  muscles 

occurs  it  is  termed  "amyotrophic  lateral  sclerosis." 


THE  NERVOUS  SYSTEM.  515 

Transverse  or  diffuse  cord  lesions  above  the  lumbar  enlargement 
produce  usually  anaesthesia  below  the  level  of  the  lesion  and  almost 
invariably  relaxation  of  the  sphincters. 

The  earliest  stages  of  peripheral  neuritis  are  usually  recogniza- 
ble, despite  a  lively  knee-jerk,  by  the  predominant  sensory  symp- 
toms and  the  etiology. 

Multiple  sclerosis  presents,  in  typical  cases,  intention  tremor 
(see  above,  page  44),  nystagmus  (page  16),  and  staccato  speech. 
In  atypical  cases  diagnosis  is  difficult  and  cases  are  often  mistaken 
for  hysteria. 

Almost  any  chronic  joint  disease,  except  tuberculosis,  may  be 
associated  with  increased  reflexes.  Diagnosis  depends  on  the  ab- 
sence of  other  causes  for  the  increase. 

Other  Deep  Reflexes. — The  Achilles  reflex  is  best  obtained  by 
having  the  patient  kneel  on  the  seat  of  a  well-padded  chair,  with 
his  feet  unsupported,  while  we  strike  the  Achilles  tendon.  The 
significance  of  its  absence  or  increase  is  practically  the  same  as  that 
just  given  for  the  knee-jerk,  but,  since  it  represents  a  slightly  lower 
position  in  the  spinal  cord,  it  may  be  affected  earlier  than  the  knee- 
jerk  in  any  covd  disease  which  begins  at  the  bottom  of  the  cord  and 
travels  up.  Thus  in  tabes  I  have  known  the  Achilles  reflex  absent 
when  the  knee-jerk  still  persisted. 

Ankle  clonus  occurs  in  spastic  conditions  of  the  legs  or  in  any 
disease  which  increases  the  other  leg  reflexes.  It  is  obtained  by 
supporting  the  patient's  leg  in  a  state  of  such  relaxation  as  can  be 
obtained,  then  suddenly  and  quickly  forcing  the  foot  up  as  far  as  it 
will  go  toward  the  shin,  and  holding  it  in  this  position.  A  clonic 
spasm  results,  which  in  true  ankle  clonus  persists  as  long  as  we 
choose  to  hold  the  foot  in  this  position.  Spurious  clonus  is  obtained 
when  only  a  fesv  contractions  occur,  the  muscle  then  relaxing.  This 
spurious  clonus  can  often  be  obtained  in  neurasthenic  and  hysterical 
states,  and  has  not  the  significance  of  true  clonus. 

Kernig's  sign  is  a  reflex  contraction  of  the  ham-string  muscles, 
obtained  by  flexing  the  thigh  on  the  trunk  at  a  right  angle  (as  in 
the  ordinary  sitting  position)  and  then  attempting  to  extend  the 


516  PHYSICAL  DIAGNOSIS. 

lower  leg.  Its  motion  is  arrested  about  half  way  between  the  right 
angle  and  full  extension. 

This  reflex  is  of  some  value  in  the  diagnosis  of  meningitis,  though 
allowance  must  be  made  for  the  stiffness  of  old  age.  The  sign  is  by 
no  means  pathognomonic,  but  is  of  some  confirmatory  value. 

The  deep  reflexes  of  the  arms  (wrist,  biceps,  and  triceps  tendon) 
are  obtained  by  snapping  these  tendons  sharply  with  the  finger. 
Decrease  in  these  reflexes  we  cannot  perceive,  since  they  are  only 
obtainable  when  increased.  They  are  increased  in  practically  the 
same  diseases  which  increase  the  leg  reflexes,  and  also  in  some 
chronic  joint  troubles. 

The  jaw-jerk  is  obtained  by  asking  the  patient  to  let  the  lower 
jaw  drop  fully,  placing  a  finger  on  the  chin  and  percussing  that  finger 
as  in  percussion  of  the  chest. 

3.  Superficial  Reflexes. — A  "ticklish"  person  is  one  whose  su- 
perficial reflexes  (skin  and  muscles)  are  very  lively.  Among  path- 
ological reflexes  of  this  type  : 

(a)  The  Babinski  reflex  is  the  most  important.  It  is  a  modifica- 
tion or  reverse  of  the  normal  plantar  reflex,  which  crumples  up  the 
toes  toward  the  sole  of  the  foot  if  the  skin  of  the  foot  is  tickled. 

To  obtain  the  Babinski  reflex,  bare  the  patient's  foot  and  draw 
the  blunt  end  of  a  pencil  along  the  inner  side  of  the  sole  from  heel 
to  toe  with  moderate  pressure.  If  the  great  toe  cocks  up  toward 
the  shin,  Babinski's  reflex  is  present.  Sometimes  several  other  toes 
spread  laterally  and  follow  the  great  toe. 

The  reflex  is  obtained  on  the  paralyzed  side  in  hemiplegia  and 
other  lesions  involving  the  motor  tract. 

(£)  The  cremasteric  reflex  draws  the  testis  tight  up  against  the 
body  (as  after  a  cold  bath)  when  the  skin  and  muscles  on  the 
inner  side  of  the  thigh  are  gathered  up  and  firmly  grasped  in  the 
hand. 

(c)  The  abdominal  and  epigastric  "  tickle  reflexes  "  are  excited 
by  lightly  and  quickly  stroking  the  skin  of  these  parts  with  a  pen- 
cil point  or  something  of  the  sort. 

The  presence  of  cremasteric,  abdominal,  and  epigastric  reflexes 
indicates  that  the  portion  of  the  spinal  cord  in  which  they  are  rep- 


THE  NERVOUS  SYSTEM.  517 

resented  (upper  lumbar  and  lower  dorsal  regions)  is  functionally 
sound.  The  absence  of  these  reflexes,  however,  signifies  nothing, 
for  in  many  healthy  persons  they  cannot  be  excited. 

(d*)  The  reflex  of  ivinking  excited  by  the  ordinary  stimuli  signi- 
fies the  approximately  normal  conductivity  of  the  fifth  and  seventh 
nerves  (trigeminal  and  facial). 

4.  Sphincteric  Reflexes. — The  sphincters  of  the  bladder  and  rec- 
tum are  kept  closed  in  the  normal  adult  by  reflex  contraction  ex- 
cited by  the  presence  of  urine  and  faeces.     If  there  is  no  aware- 
ness of  faeces  at  the  anus  or  of  urine  at  the  neck  of  the  bladder, 
owing  to  destruction  of  the  conducting  nerves  or  spinal  nerve-cen- 
tres, involuntary  urination  and  defecation  occur. 

This  is  the  case  in  transverse,  diffuse,  or  compression  myelitis 
above  the  segment  (fourth  and  fifth  sacral)  where  the  centres  for 
bladder  and  rectum  are  represented; '  also  in  tabes  dorsalis,  dementia 
paralytica,  and  less  often  in  other  chronic  spinal  diseases.  Periph- 
eral neuritis  and  brain  lesions  rarely  affect  the  sphincters. 

In  deep  coma  from  any  cause  (epilepsy,  cerebral  hemorrhage) 
the  sphincters  may  be  relaxed,  owing  to  the  abolition  of  sensation. 

5.  Sexual  Power. — Sexual  power  may  be  regarded  as  a  reflex  in 
the  presence  of  a  particular  stimulus,  and  is  diminished  or  lost  in 
chronic  cord  diseases  involving  the  first  and  second  sacral  segments 
(lumbar  enlargement)  or  the  nerves  leading  to  them,  e.g.,  in  tabes, 
some  cases  of  myelitis  and  dementia  paralytica,  etc.     Temporary 
increase  of  power  may  precede  the  diminution. 

IV.  Electrical  Reactions. 

In  health  a  sharp  contraction  occurs  if  a  faradic  current  is  ap- 
plied to  a  nerve  or  over  a  muscle,  and  a  similar  contraction  can  be 
obtained  with  the  galvanic  current  just  when  the  circuit  is  closed 
or  broken,  but  not  when  the  current  is  passing. 

In  contrast  with  these  conditions  is  the  reaction  of  degeneration. 

1  It  must  be  remembered  that  these  nerves  arise  from  the  cord  at  the  level 
of  the  first  lumbar  vertebra,  though  they  do  not  issue  from  the  spinal  column 
till  the  fourth  and  fifth  sacral  foramina  are  reached. 


518  PHYSICAL  DIAGNOSIS. 

When  this  is  present  we  obtain  no  muscular  twitching  with  the 
faradic  current  and  none  over  the  nerve  with  the  galvanic;  but 
with  the  galvanic  over  the  muscle  a  slow,  worm-like  contraction  oc- 
curs, and  the  response  to  the  positive  pole  is  as  good  as  to  the  neg- 
ative, or  better,  whereas  normally  there  is  far  better  response  to 
the  negative.  This  is  the  complete  reaction  of  degeneration;  in 
partial  reactions  of  degeneration  all  the  normal  reactions  may  be 
present,  but  diminished  in  intensity. 

Reaction  of  degeneration  occurs  in  all  diseases  affecting  the  an- 
terior motor  horns  of  the  cord  or  their  prolongations  downward  in 
the  peripheral  nerves ;  for  example,  in  anterior  poliomyelitis,  pro- 
gressive muscular  atrophy,  transverse  or  pressure  myelitis,  and  all 
severe  forms  of  peripheral  neuritis.  In  brain  lesions  this  reaction 
rarely  occurs. 

In  prognosis  a  reaction  of  degeneration  persisting  after  six  to 
twelve  weeks  is  unfavorable  for  recovery  of  the  use  of  the  muscles 
in  which  it  occurs.  If  reaction  of  degeneration  is  absent  or  partial 
from  the  start,  prognosis  is  for  relatively  speedy  recovery,  weeks 
rather  than  months. 

F.   Speech  and  Handwriting. 

Aphasia,  the  loss  of  the  power  to  speak  or  understand  speech, 
despite  normal  hearing  and  muscular  powers,  occurs  in  lesions  af- 
fecting the  third  left  frontal  and  first  left  temporal  convolutions 
of  the  brain.1 

The  lesions  producing  aphasia  may  be  permanent  anatomical 
changes  following  hemorrhage  or  tumor,  or  they  may  be  transitory, 
as  in  uraemia  and  migraine. 

The  power  to  write  or  read  letters  is  lost  (agraphia)  when  the 
angular  and  supramarginal  convolutions  are  destroyed. 

Degeneration  of  the  handwriting,  as  compared  with  the  standard 
of  former  years,  is  often  a  helpful  bit  of  evidence  in  the  diagnosis 
of  dementia  paralytica,  but  may  occur  temporarily  in  various  fatigue 
states. 

1  In  some  left-handed  persons  the  centres  are  on  the  right  side  of  the  brain. 


THE  NERVOUS  SYSTEM.  519 


VI.    Trophic  or  Vasonwtor  Disorders. 

Trophic  lesions  of  the  joints,  muscles  (atrophy),  skin,  and  nails 
have  already  been  exemplified  (pages  499  and  52).  They  blend  with 
and  are  by  some  explained  as  the  results  of  vascular  changes  (vaso- 
motor}.  Herpes  labialis  (''cold  sore")  and  herpes  zoster  ("shin- 
gles") certainly  seem  to  give  every  evidence  of  being  due  to  nerve 
nutritive  disorders  and  not  to  vascular  changes.  The  acute  bedsores 
which  form  in  myelitis,  the  "  angioneurotic "  local  swellings  which 
appear  here  and  there  in  certain  persons,  and  the  local  syncope  or 
asphyxia  which  sometimes  lead  to  Raynaud's  form  of  gangrene, 
seem  to  need  both  nerve  and  vessel  changes  to  explain  them. 

In  brain  lesions  these  trophic  and  vasomotor  changes  are  much 
rarer  than  in  disease  of  the  cord  and  peripheral  nerves. 

VII.   The  Examination  of  Psychic  Functions. 

The  diagnosis  of  the  mental  factors  of  disease  forms  an  impor- 
tant part  of  the  study  not  only  of  neurology,  but  of  all  diseases 
wherever  situated ;  but  as  it  cannot  be  called  physical  diagnosis,  it 
falls  outside  the  scope  of  this  book,  except  in  so  far  as  loss  of  con- 
sciousness, coma,  may  be  considered  under  this  heading. 

COMA. 

The  causes  of  coma  are  identical  with  the  causes  of  convulsions. 
Every  disease  which  causes  the  one  may  cause  the  other;  hence  all 
that  is  here  said  on  the  diagnosis  of  coma  applies  equally  well  to 
the  diagnosis  of  convulsions.  Either  or  both  may  result  from : 

1.  Apoplexy   (including   cerebral   hemorrhage,  embolism,  and 
thrombosis). 

2.  Uraemia  and  hepatic  toxaemia 

3.  Diabetes. 

4.  Cerebral  concussion  (stun). 

5.  Cerebral  compression. 


520  PHYSICAL  DIAGNOSIS. 

6.  Syncope  (fainting). 

7.  Opium. 

8.  Alcohol. 

9.  Hysteria. 

10.  Epilepsy. 

11.  Gas  poisoning. 

12.  Sunstroke. 

Apoplexy  is  the  probable  diagnosis  when  an  elderly  person  who 
has  shown  no  previous  signs  of  ill-health  becomes  suddenly  and 
deeply  comatose  within  a  few  seconds  or  minutes.  If  hemiplegia  is 
present  (with  or  without  aphasia)  and  if  we  can  exclude  the  other 
causes  above  mentioned,  the  probability  of  apoplexy  is  increased. 
To  determine  hemiplegia  in  a  comatose  patient,  try  the  following 
tests : 

(a)  Lift  the  arm  and  then  the  leg,  first  on  one  side  and  then  on 
the  other,  and  let  go.  The  supported  member  falls  more  limply  on 
the  paralyzed  side. 

(6)  Pinch  or  prick  the  limbs  alternately.  The  sound  limb  may 
be  moved,  while  the  other  remains  motionless.  Pressure  over  the 
supraorbital  notch  may  bring  out  a  similar  difference  in  the  response 
of  the  two  sides. 

(c)  Try  the  knee-jerks.     On  the  paralyzed  side  the  jerk  may  be 
increased. 

(d)  Try  Habinski's  reaction.     It  may  be  present  on  the  para- 
lyzed side  or  on  both  sides. 

Urcemia. — The  diagnosis  between  apoplexy  and  uraemia  is  some- 
times impossible,  since  uraemia  may  produce  hemiplegia  and  the 
urine  in  the  two  conditions  (as  obtained  by  catheter)  may  be  identi- 
cal. Usually,  however,  the  ursemic  patient  has  previously  shown 
obvious  signs  of  nephritis — oedema,  headache  and  vomiting,  long- 
standing oliguria,  or  polyuria  with  albuminuria.  Convulsions  more 
often  precede  or  follow  the  coma  of  uraemia  than  that  of  apoplexy. 
Retinal  hemorrhages  or  albuminuric  retinitis,  if  recognized  by  oph- 
thalmoscopic  examination,  point  strongly  to  uraemia. 

The  hepatic  toxaemia  in  which  many  cases  of  cirrhosis  die  is  dis- 
tinguishable from  uraemia  only  if  the  previous  history  of  the  case  is 


THE  NERVOUS  SYSTEM.  521 

known  to  us  and  the  signs  of  liver  disease  (ascites,  jaundice,  caput 
Medusae)  are  evident. 

Diabetic  coma  is  usually  recognized  with  ease,  because  the  evi- 
dences of  advancing  diabetes  lead  gradually  up  to  it.  The  emacia- 
tion of  the  patient,  the  sweetish  odor  of  the  breath,  the  presence  of 
sugar,  and  especially  the  evidences  of  acetone  and  diacetio  acid  in 
the  catheter-urine,  are  the  essential  factors  in  diagnosis.  Dysp- 
noea ("air  hunger")  precedes  the  coma  in  about  one-third  of  the 
cases. 

Concussion  (or  stun)  after  a  blow  usually  clears  up  in  a  few 
minutes  and  so  presents  no  difficulty  in  diagnosis.  If  the  coma 
lasts  on  for  hours  or  days  (as  it  sometimes  does)  the  suspicion 
arises  that  we  are  dealing  with 

Compression.  For  this  the  evidences  are :  FoctJL  symptoms, 
convulsions,  slowing  of  the  pulse,  and  signs  of  depressed  fracture. 
To  determine  the  latter  fact  may  be  impossible  without  trephining, 
since  the  inner  table  of  the  skull  may  be  broken,  while  the  outer  is 
intact.  The  focal  signs  to  be  looked  for  are  paralyses  (ocular  or 
peripheral). 

Syncope  (or  fainting)  is  usually  over  in  a  few  minutes  and  so 
betrays  its  nature,  but  it  must  not  be  forgotten  that  a  slight  convul- 
sion may  occur  just  as  the  patient  comes  out  of  coma.  No  suspi- 
cions of  epilepsy  need  be  aroused  thereby,  but  if  there  have  previ- 
ously been  signs  of  hysteria  we  may  be  in  doubt  whether  the 
fainting  fit  is  not  of  hysterical  origin.  The  history  of  the  case,  the 
circumstances  at  the  onset  of  the  attack,  and  the  presence  or  ab- 
sence of  hysterical  behavior  during  it  usually  guide  us  aright. 

Opium  poisoning  produces  a  coma  from  which  the  patient  can 
usually  be  more  or  less  aroused.  Contracted  pupils  and  slow  respi- 
ration are  the  most  characteristic  signs.  A  laudanum  bottle  or  a 
subcutaneous  syringe  found  near  the  patient  often  assist  the  diag- 
nosis. 

Alcoholic  coma  is  rarely  complete.  The  patient  can  be  aroused. 
The  circum stances  under  which  he  is  found,  the  odor  of  alcohol  on 
the  breath,  the  absence  of  paralysis,  fever,  small  pupils,  or  urinary 
abnormalities  are  the  main  supports  in  diagnosis.  There  is  no  char- 


522  PHYSICAL  DIAGNOSIS. 

acteristic  pulse  and  the  pupils  show  no  constant  changes,  though  in 
many  cases  they  are  dilated. 

Hysterical  coma  usually  occurs  in  young  women  who  have  pre- 
viously shown  signs  of  hysteria.  In  falling  they  never  hurt  them- 
selves. The  eyelids  are  contracted,  often  tremulous,  and  when 
forcibly  pulled  open  often  expose  eyeballs  rolled  iip  so  that  the 
whites  alone  are  seen.  The  hands  are  apt  to  make  grasping  motions, 
and  there  are  irregular,  semipurposive  movements  of  various  parts 
of  the  body.  A  startling  word  may  arouse  the  patient,  but  anaes- 
thesia to  pain  (over  one-half  or  all  the  body)  is'often  complete. 

Postepileptic  coma  is  usually  recognized  with  ease,  because  of 
the  convulsions  which  precede  it  and  which  are  usually  known  to 
have  occurred  at  intervals  before.  The  scars  of  previous  falls  may 
be  found  on  the  head. 

Gas  poisoning  rarely  presents  any  diagnostic  difficulties,  because 
the  circumstances  under  which  the  patient  is  found  make  clear  the 
cause  of  his  condition.  An  odor  of  gas  may  hang  about  his  breath 
for  some  hours. 

Sunstroke  is  recognized  by  the  state  of  the  weather  and  the  pres- 
ence of  a  very  high  temperature  (106°,  110°,  115°  F.,  or  even 
more).  There  is  no  other  characteristic  sign.  This  condition  is  to 
be  distinguished  from  heat  exhaustion  in  which  there  is  no  fever  and 
no  coma. 


APPENDICES. 


APPENDIX  A. 

DISEASES  OF  THE  MEDIASTINUM 
I.  MEDIASTINAL  TUMORS. 

NEW  growths  of  the  mediastinal  glands'  usually  manifest  theii 
presence  by  the  following  symptoms  and  signs : 

(1)  Cachexia  and  substernal  pain. 

(2)  Evidence  of  pressure  against : — 

(a)  The  gullet. 

(V)  The  windpipe  or  primary  bronchi. 

(c)  The  large  venous  trunks. 

(d)  Nerves  which  pass  through  the  mediastinum. 

(e)  The  subclavian  arteries. 
(/)  The  heart. 

(g)  The  ribs,  clavicle,  or  sternum. 

(3)  Secondary  deposits  in  the  cervical  or  axillary  glands. 

(a)  By  pressure  on  the  gullet  swallowing  may  be  rendered  diffi- 
cult or  impossible  (dysphagia) . 

(b  )  By  pressure  on  the  windpipe  may  be  produced  displacement 
of  the  latter  to  one  side,  or  fixation  so  that  it  cannot  be  moved  in 
any  direction.  The  larynx  may  be  drawn  down  into  a  noticeably 
low  position,  and  the  laryngoscope  may  demonstrate  that  the  tra- 
cheal  wall  is  bulged  inward  by  the  pressure  of  the  new  growth 
upon  it. 

Dyspnoea,  either  inspiratory  or  expiratory,  or  both,  and  often 

'Tuberculous  glands  not  being  here  included. 


524  PHYSICAL  DIAGNOSIS. 

of  noisy  strident  type,  may  result  from  stenosis  of  the  trachea  01 
primary  bronchi.  Owing  to  pressure  on  one  of  the  large  bronchi, 
the  resonance  and  breath  sounds  and  fremitus  may  be  diminished 
over  the  corresponding  lung,  in  which  finally  abscess  or  gangrene 


FIG.  236.— Sarcoma  of  Mediastinum  and  Cervical  Gland.    Vena  cava  superior  obstructed. 

may  develop,  owing  to  the  retention  and  decomposition  of  the 
bronchial  secretions. 

(c)  If  the  pulmonary  veins  are  pressed  upon,  a  systolic  murmur 
may  be  audible  in  the  left  back,  and  congestion  of  the  lungs  may 
ensue. 

Pressure  on  the  innominate  and  subclavian  veins  produces  cya- 
nosis or  oedema  of  the  head,  neck,  shoulder,  and  arm,  while  the 
superficial  veins  of  the  chest  may  become  enlarged  and  prominent 
owing  to  an  attempt  at  collateral  circulation,  especially  if  the  vena 
cava  superior  is  pressed  upon.  Fluid  may  accumulate  in  one  or 


DISEASES   OF  THE  MEDIASTINUM.  525 

both  pleural  cavities  if  the  vena  azygos  or  thoracic  duct  is  in- 
volved (see  Fig.  236). 

Vo5)  Aphonia  or  hoarseness  points  to  pressure  on  the  recurrent 
laiyngeal  nerve,  and  on  laryngoscopic  examination  one  vocal  cord 
may  be  found  in  the  cadaveric  position.  Inequality  of  the  pupils, 
due  to  pressure  on  the  sympathetic  nerves,  is  not  uncommon,  and 
severe  pain  along  the  distribution  of  the  intercostals  or  running 
down  the  arm  indicates  that  the  spinal  ganglia  or  brachial  plexus 
are  pressed  upon.  Much  rarer  are  symptoms  of  pressure  on  the 
vagus  (slowing  or  quickening  of  the  heart)  and  on  the  phrenic 
nerve  (hiccup,  unilateral  spasm,  or  paralysis  of  the  diaphragm). 

(e)  "Weakening  or  delay  in  one  radial  pulse  may  be  due  to  press- 
ure on  the  subclavian  artery. 

(/)  Occasionally  the  heart  itself  may  be  pushed  out  of  place. 

(g)  Pressure  of  the  new  growth  against  the  bones  of  the  chest 
may  give  rise  to  an  area  of  percussion  dulness  under  or  near  the 
manubrium,  which,  however,  is  not  likely  to  show  itself  until  late 
in  the  course  of  the  disease  when  the  new  growth  has  reached  a 
considerable  size.  In  many  cases  there  is  tympanitic  resonance  in- 
stead of  dulness  over  the  affected  area.  The  ribs  or  clavicle  may 
be  pushed  forward,  but  this  is  not  usually  the  case.  Occasionally 
the  new  growth,  if  very  vascular,  may  pulsate  like  an  aneurism  or 
transmit  the  pulsations  of  the  heart  to  the  chest  wall,  and  a  systo- 
lic murmur  may  be  heard  over  the  pulsating  area,  so  that  the  resem- 
blance to  aneurism,  is  increased. 

Differential  Diagnosis. 

Mediastinal  tumors  may  be  mistaken  for 

(1)  Aneurism  of  the  aortic  arch. 

(2)  Syphilitic  stenosis  of  a  bronchus. 

(3)  Phthisis. 

Aneurism  may  be  confounded  with  mediastinal  new  growths 
even  by  the  most  competent  observers.  Tactile  thrill,  diastolic 
shock,  and  tracheal  tugging,  if  present,  should  suggest  aneurism. 
If  these  signs  are  absent,  aneurism  may  still  be  present  but  cannot 


526  PHYSICAL  DIAGNOSIS. 

be  surely  diagnosed.  The  degree  of  anaemia  and  emaciation  is  usu- 
ally greater  in  malignant  disease  than  in  aneurism,  but  this  is  not 
always  the  case.  The  presence  of  secondary  nodules  in  the  neck  or 
armpit  speaks  strongly  in  favor  of  new  growth. 

Stenosis  of  a  bronchus,  due  to  syphilis  and  giving  rise  to  dysp- 
noea, cough,  stridor,  pulmonary  atelectasis,  may  be  very  difficult  to 
distinguish  from  mediastinal  growth,  but  the  degree  of  anaemia  and 
emaciation  is  usually  less  in  syphilis,  and  the  beneficial  results  of 
antisyphilitic  treatment  may  render  the  diagnosis  possible,  espe- 
cially if  there  is  evidence  of  syphilis  elsewhere  in  the  body  or  in 
the  history  of  the  case. 

Phthisis  may  be  suggested  by  the  weakness,  emaciation,  and 
persistent  cough  produced  by  mediastinal  growths,  but  should  be 
easily  excluded  by  the  examination  of  the  lungs  and  sputa. 

II.  MEDIASTINITI& 

The  acute  suppurative  forms  of  this  rare  disease  do  not  give  rise 
to  any  characteristic  physical  signs  in  the  chest. 

The  evidences  of  chronic  fibrous  mediastinitis  have  been  already 
sufficiently  considered  in  connection  with  adhesive  pericarditis. 

III.    TUBERCULOSIS  OF  THE  MEDIASTINAL  GLANDS. 

Probably  every  case  of  pulmonary  tuberculosis  is  preceded  or 
accompanied  by  tuberculosis  of  the  bronchial  lymph  glands,  and  in 
numberless  cases  the  tuberculous  process  never  gets  beyond  these 
glands  but  is  choked  off  there.  In  post-mortem  examinations  of 
children,  no  matter  what  the  cause  of  death,  it  is  exceptional  not 
to  find  the  bronchial  glands  tuberculous. 

Nevertheless  the  disease  can  but  rarely  be  recognized  during 
life.  We  may  suspect  it  if,  in  a  child  showing  tuberculous  cervical 
glands  or  phthisis,  we  find  evidence  of  pressure  upon  the  right 
bronchus,  increased  tactile  fremitus  above  the  manubrium,  lateral 
displacement  of  the  trachea,  or  weakening  of  the  pulse  during  in- 
spiration. If  a  bronchus  is  compressed,  the  resonance,  tactile 


ACUTE  ENDOCARDITIS.  527 

freniitus,  and  breath  sounds  are  diminished  over  the  correspond- 
ing lung.  Wiederhofer  lays  stress  upon  an  increase  in  the  inten- 
sity of  the  expiratory  murmur  over  the  situation  of  the  left  primary 
bronchus. 


APPENDIX  B. 
ACUTE  ENDOCARDITIS. 

Whether  the  disease  be  of  the  benign  or  of  the  malignant  (sep- 
tic) type,  the  results  of  physical  examination  of  the  heart  are  usu- 
ally very  equivocal.  We  may  guess  that  endocarditis  is  present 
owing  to  the  presence  of  a  cause  (rheumatism),  of  a  fever  not  oth- 
erwise explained,  of  a  rapid  irregular  pulse  of  low  tension,  but  the 
physical  signs  over  the  heart  will  not  usually  assist  our  guess  ma- 
terially. 

Murmurs  are  often  present  but  have  usually  the  characteristics 
of  "  functional "  murmurs  (systolic,  limited,  soft,  without  accentu- 
ation of  the  pulmonic  second  sound  or  cardiac  enlargement).  If 
we  can  observe  the  advent  of  a  diastolic  murmur  in  such  a  case,  we 
may  fairly  attribute  it  to  a  fresh  endocarditis  of  the  aortic  (very 
rarely  of  the  pulmonic)  valve,  but  if  we  have  not  had  the  oppor- 
tunity to  examine  the  heart  previous  to  the  onset  of  the  present 
attack  it  is  impossible  to  exclude  a  long-standing  valvular  lesion  as 
the  cause  of  the  murmur. 

If  murmurs  come  and  go  from  day  to  day,  or  suddenly  increase 
in  intensity,  we  may  suspect  an  acute  endocarditis,  especially  if  a 
musical  murmur  is  present  or  if  there  be  evidence  of  embolism. 

Inspection,  palpation,  and  percussion  usually  yield  no  signs  of 
importance.  There  is  no  enlargement  of  the  heart,  no  accentuation 
of  the  second  sounds,  and  no  evidence  of  stasis. 


528  PHYSICAL  DIAGNOSIS. 

APPENDIX  C. 

PHYSICAL  EXAMINATION  OP  THE  CHEST  IN  INFANTS. 

(1)  Tactile  fremitus  and  voice  sounds  can  be  investigated  only 
in  case  the  child  cries  or  crows.     The  cry-sound  is  intensified  over 
solidified  areas  and  may  or  may  not  be  lost  over  fluid  accumula- 
tions. 

(2)  Percussion  must  be  very  delicately  performed  if  we  are  to 
avoid  setting  the  whole  chest  in  vibration  with  every  stroke.     It  is 
best  to  strike  wholly  with  the  finger,  keeping  the  hand  (as  well  as 
the  wrist  and  arm)  unmoved. 

(3)  In  listening  to  an  infant's  lungs  patience  and  concentration 
are  essential.     The  child  is  apt  to  stop  breathing  when  the  exami- 
nation begins,  and  we  have  to  wait  patiently  to  catch  the  long-de- 
layed inspiration  "  on  the  wing, "  as  it  were,  before  the  long  expi- 
ratory wail  begins.     The  inspiration,  when  it  does  come,  is  unusu- 
ally intense  owing  to  the  thinness  of  the  chest  in  infancy. 

(4)  Long  flexible  rubber  tubes  connecting  the  chest-piece  of  the 
stethoscope  with  the  ear-pieces  are  very  convenient  when  examin- 
ing a  wriggling  child  (see  Fig.  83,  p.  117),  as  they  make  it  possible 
to  hold  the  chest-piece  in  position  despite  the  constant  movements 
of  the  struggling  sufferer. 

(5)  It  is  advisable  to  examine  first  the  back  while  the  child  is 
held  in  the  mother's  arms  with  its  back  to  the  physician. 

(6)  Children  almost  always  cry  if  made  to  lie  down  flat.     If 
we  wish  to  bring  out  the  cry  sound  in  order  to  test  the  vocal  and 
tactile  fremitus,  this  is  a  simple  and  humane  method  of  producing 
it.     If,  on  the  other  hand,  peace  is  what  we  most  desire,  it  is  best 
to  avoid  putting  the  child  in  a  recumbent  position. 

(7)  There  is  no  type  of  breathing  peculiar  to  children  or  in- 
fants.    Puerile  breathing  is  simply  vesicular  breathing  heard  very 
distinctly  on  account  of  the  thinness  of  the  chest.     If,  in  a  healthy 
child,  the  expiratory  murmur  is  prolonged  and  high-pitched,  this  is 
probably  because  the  child  blows  out  the  breath  forcibly  in  the 
effort  to  breathe  deeply  as  it  is  told  to  do.     A  young  infant  never 


RADIOSCOPY  OF  THE  CHEST.  529 

does  this,  and  its  breathing  is  like  that  of  adults  except  that  it  is 
more  rapid,  more  irregular,  and  better  heard. 


APPENDIX  D. 

RADIOSCOPY  OF  THE  CHEST. 

Radioscopy  gives  assistance  in  the  diagnosis  of  diseases  of  the 
chest  in  two  ways : 

1.  Through  the  use  of  the  fluoroscopic  screen. 

2.  Through  the  use  of  radiographs. 

Those  who  are  accustomed  to  the  use  of  the  fluoroscope  gain 
far  more  information  from  it  than  from  radiographs,  but  the  record 
of  the  photographic  plate  is  objective,  permanent,  and  demon- 
strable, while  the  impressions  gained  from  the  fluoroscope  are  more 
apt  to  be  modified  by  the  personal  equation. 

For  the  present,  therefore,  we  need  both  methods. 

I  shall  not  attempt  to  discuss  the  advantages  of  the  various 
forms  of  apparatus  used  for  producing  Roentgen  rays  in  a  Crookes 
tube ;  the  subject  would  carry  me  beyond  my  depth  as  well  as  be- 
yond the  limits  of  this  book ;  but  whatever  form  of  instrument  is 
used,  the  vacuum  in  the  tube  should  be  less  perfect  when  we  desire 
to  use  it  for  the  chest  than  when  searching  for  foreign  bodies  or 
studying  fractures.  We  need  a  "  low  "  or  "  soft "  tube  which  gives 
rays  of  a  relatively  slight  degree  of  penetration.  With  high  pene- 
tration rays  the  outlines  of  the  solid  organs  are  less  distinct  because 
the  rays  traverse  the  heart  and  liver  almost  as  easily  as  they  do  the 
lungs.  If  the  penetrating  power  is  less,  the  rays  are  arrested  by 
the  solid  organs,  but  not  by  the  lungs,  and  hence  the  outlines  of  the 
former  become  visible. 

/.  The  Use  of  the  Fluoroscope. 

1.  It  is  advisable  to  remain  in  a  dark  room  or  to  wear  smoked 
glasses  for  a  short  time  before  attempting  to  use  the  fluoroscope. 
This  applies  especially  to  beginners.     Skilled  observers  do  not  need 
34 


530  PHYSICAL  DIAGNOSIS. 

such  preparation  of  the  retina,  but  many  novices  who  complain  at  first 
that  they  can  "  see  absolutely  nothing  "  when  they  apply  the  fluoro- 
scope  to  the  chest,  find  their  vision  suddenly  and  permanently  im- 
proved after  fifteen  minutes  in  a  dark  room.  Practice  increases  our 
powers  with  the  fluoroscope  as  much  as  it  does  with  the  micro- 
scope, and  it  is  unreasonable  to  expect  to  see  from  the  first  all  that 
an  expert  sees. 

2.  The  patient  should  be  placed  at  least  four  feet  from  the  tube, 
else  there  is  likely  to  be  distortion  and  magnification  of  the  shad- 
ows corresponding  to  the  organs  examined.     The  tube  should  be 
placed  at  such  a  height  as  to  be  opposite  the  most  important  object 
to  be  examined,  and  always  in  the  median  line. 

3.  Patients  may  be  examined  either  in  the  upright  position — 
the  tube  about  two  feet  from  the  patient's  back — the  fluoroscope 
resting  against  the  chest — or  in  the  recumbent  position,  supported 
on  a  canvas  cot  with  the  tube  underneath.     I  prefer  the  upright 
position.     The  patient's  arms  should  always  be  extended  forward 
so  as  to  get  the  scapulae  out  of  the  way. 

4.  To  concentrate  the  light  upon  a  spot  of  special  interest,  we 
may  use  a  metal  plate  with  a  rectangular  opening  about  two  by 
three  inches  near  one  end.     When  this  plate  is  held  between  the 
tube  and  the  patient,  so  that  the  opening  is  opposite  the  spot  to 
be  examined,  the  rays  pass  through  the  opening,  but  are  intercepted 
by  the  metal  around  it.     The  hand  which  holds  this  plate  should 
be  protected  from  the  action  of  the  rays. 

5.  To  mark  on  the  chest  the  outlines  of  the  shadows  seen  with 
the  fluoroscope,  a  pencil  enclosed  in  a  tube  of  brass  is  useful ;  the 
brass  jacket  makes  the  pencil  visible  and  enables  us  to  adjust  its 
point  to  the  outlines  on  the  chest.     An  ordinary  pencil  is  pene- 
trated by  the  rays  completely,  and  it  is  hard  to  draw  with  a  pencil 
which  we  cannot  see. 

11.    The  Normal  Fluoroscopic  Picture  (see  Frontispiece). 

The  lungs  appear  as  the  lightest  part  of  the  field  owing  to  the 
large  amount  of  air  they  contain ;  at  the  end  of  full  inspiration, 
they  become  still  lighter.  Against  the  light  lung  areas,  the  out- 


RADIOSCOPY  OF  THE  CHEST.  531 

lines  of  the  ribs  and  of  the  vertebral  column  (with  the  sternum  super- 
imposed) are  clearly  visible.  Less  clear,  but  usually  quite  distin- 
guishable, are  the  outlines  of  the  heart  and  the  upper  border  of  the 
liver.  A  slight  shadow  (see  Fig.  174)  is  often  noticed  just  to  the 
right  and  to  the  left  of  the  heart  in  a  position  corresponding  to  the 
larger  bronchi.  The  spleen  is  not  usually  to  be  made  out  clearly, 
but  the  upper  surface  of  the  diaphragm  above  it  is  generally  visible. 
The  contractions  of  the  heart  and  the  movements  of  the  diaphragm 
are  usually  clear,  and  any  restriction  of  the  respiratory  excursion 
on  one  side  can  be  noted,  though  the  fluoroscope  has  no  advantages 
over  the  inspection  of  Litten's  diaphragm  shadow  (see  p.  76)  for 
this  purpose. 

Abrams  has  noted  that  if  the  skin  of  the  precordia  is  irritated 
by  cold  or  pain,  a  reduction  in  the  size  of  the  heart  occurs  ("heart 
reflex  ")  for  a  few  seconds. 

In  children  all  these  phenomena  are  especially  clear,  owing  to 
the  thinness  of  their  chest  walls  and  we  note  at  once  how  much 
more  horizontal  the  child's  heart  is  than  the  adult's. 

III.  The  Fluoroscope  in  Disease. 

I  shall  mention  first  those  diseases  in  which  the  fluoroscope  fur- 
nishes us  the  most  valuable  information. 

1.  Aneurism. — Small  aneurisms  of  the  transverse  or  descending 
aorta  may  sometimes  be  recognized  by  the  x-rays  when  no  other 
method  of  physical  examination  yields  satisfactory  evidence.     An 
abnormal  shadow  appears  at  one  side  of  the  sternum  (see  Fig.  237) 
and  may  sometimes  be  seen  to  pulsate.     In  other  cases  the  fluoro- 
scopic  evidence  is  not  the  only  evidence,  but  tends  to  confirm  or 
dispel  suspicions  aroused  by  the  ordinary  methods  of  examination. 

Aneurism  of  the  heart  itself  is  recognizable,  according  to  F.  H. 
Williams,  by  the  fluoroscopic  examination.  No  other  method  of 
examination  gives  us  any  evidence  of  such  a  lesion. 

2.  Determination  of  the  Cardiac  Outlines  in  Patients  with  Em- 
physema and  Fat  Chest  Walls. — Emphysema  spoils  cardiac  percus- 
sion and  interferes  with  inspection  an'd  palpation.     But  in  fluoro- 


532 


PHYSICAL  DIAGNOSIS. 


Eio.  237.— Radiograph  of  Thoracic  Aneurism. 


RADIOSCOPY  OF  THE  CHEST.  533 

scopic  work  emphysema  is  a  boon  and  a  blessing,  for  it  renders  the 
cardiac  outlines  more  distinct  than  usual.  Hence,  for  determining 
the  size  and  position  of  the  heart  in  such  cases,  the  z-rays  give 


FIG.  238. — Right-sided  Pneumothorax  seen  from  Behind.  The  collapsed  right  lung  is  seen 
against  the  spinal  column  and  surrounded  by  an  unnaturally  bright  area  corresponding  to 
the  empty  thoracic  cavity.  The  shadow  of  the  heart  appears  vaguely  on  the  left  side  of  the 
spine. 

genuine  assistance,  as  they  also  do  when  mapping  out  the  heart  in 
women  with  large  breasts  and  fat  chest  walls. 

3.  Central  Pneumonia. — Williams  and  others  have  succeeded 
iu  identifying  foci  of  solidification  beneath  the  surface  of  the  lungs 
when  no  other  physical  signs  could  be  obtained.  It  must  be  re- 


534  PHYSICAL  DIAGNOSIS. 

membered,  however,  that  congestion  of  the  lung,  oedema,  atelec 
tasis,  and  pleural  thickening  produce  shadows  similar  to  those  of 
solidified  lung. 

4.  Tuberculosis. — It  is  still  a  matter  of  doubt  whether  tubercu- 
lous foci  can  be  recognized  by  the  fluoroscope  before  the  disease  has 
progressed  sufficiently  to  produce  localized  rales,  diminished  breath 
sounds,  or  restriction  of  Litten's  phrenic  phenomenon. 

Slight  opacities  have  been  noted  in  cases  which  later  turned  out 


FIG.  239.— Aneurismal  Sac,  Radiographed  from  Behind. 

to  be  tuberculosis,  and  which  had  not  previously  been  diagnosed, 
but  the  shadows  perceived  by  the  fluoroscope  are  capable  of  many 
interpretations  and  correspond  (as  above  said)  to  various  patholog- 
ical conditions.  Old  quiescent  foci  may  appear  like  advancing  le- 
sions and  thus  lead  to  serious  errors.  We  do  not  want  to  hurry  a 
patient  off  to  Colorado  or  Davos  on  account  of  the  shadow  thrown 


RADIOSCOPY  OF  THE  CHEST.  535 

by  a  long-healed  lesion.  Further,  in  some  cases  of  rheumatism, 
anaemia,  debility,  and  convalescent  typhoid,  appearances  very  simi- 
lar to  those  of  tuberculosis  may  be  found  (Williams).  Hence  the 
interpretation  of  slight  lung  shadows  in  cases  of  suspected  incipient 
phthisis  is  by  no  means  easy. 

Advanced  phthisis   renders  the  lungs  relatively  opaque  to  the 


FIG.  240.— Aneurismul  Sac  Radiographed  from  in  Front. 

Roentgen  rays  except  where  extensive  excavation  has  occurred  ; 
here  we  see  a  light  area  in  a  dark  background. 

No  satisfactory  radiographs  of  cases  of  incipient  phthisis  have 
so  far  been  published,  so  far  as  I  am  aware. 

5.  Pleuritic  Effusions. — The  displacement  of  the  heart  is  some- 
times better  shown  by  the  arrays  than  by  ordinary  methods  of  ex- 
amination, since  t'he  compensatory  hypertrophy  of  the  sound  lung, 


536  PHYSICAL  DIAGNOSIS. 

which  interferes  with  percussion  and  palpation  of  the  heart,  renders 
radioscopy  easier. 

The  fluid  exudate  intercepts  the  rays  perceptibly,  and  when  the 
movements  of  the  diaphragm  are  not  abolished  on  the  affected  side, 
the  line  corresponding  to  the  surface  of  the  fluid  can  be  seen  to 

6.  Emphysema.  — The  lungs  become  unusually  transparent  and 
owing  to  the  low  position  of  the  diaphragm  the  heart  descends  and 
assumes  a  very  vertical  position  ("ptosis  of  the  heart");  these 
points  are  very  clearly  seen  with  the  fluoroscope. 

Radiographs. 

But  little  use  has  thus  far  been  made  of  radiographs  in  study- 
ing diseases  of  the  chest.  The  movements  of  the  heart,  of  the 
chest  walls,  and  of  the  diaphragm  render  all  the  outlines  indistinct. 
For  aneurisms,  especially  those  containing  a  thick  layer  of  clot,  and 
for  intrathoracic  tumors,  radiographs  may  be  very  useful,  and 
bronchial  lymph  glands  are  sometimes  rendered  visible. 


APPENDIX  E. 
THE  SPHYGMOGRAPH. 

This  instrument  consists  of  a  system  of  levers  by  means  of  which 
the  pulsations  of  the  radial  artery  are  transferred  to  a  needle  whose 
oscillations  can  be  graphically  recorded  upon  a  piece  of  smoked  pa- 
per. It  is  a  very  fascinating  little  toy,  but  in  its  present  form  is 
almost  devoid  of  practical  usefulness  owing  to  the  impossibility  of 
eliminating  the  personal  equation  when  using  it.  The  size  and,  to 
a  certain  extent,  the  shape  of  the  wave  traced  upon  the  smoked 
paper  can  be  influenced  at  will  by  the  amount  of  pressure  with 
which  the  instrument  is  applied  to  the  wrist.  If  an  instrument  is 
move  up  and  down  with  respiration.  .  During  inspiration  the  heart 
moves  toward  the  side. on  which  the  exuda'te  is.  (Greene.) 

Small  fluid  accumulations  flatten  the  normal  curve  of  the  upper 
surface  of  the  diaphragm  by  filling  up  the  chink  between  the  chest 
wall  and  the  diaphragm. 


THE  SPHYGMOGRAPH. 


537 


applied  with  a- pressure  of  three  ounces  to  the  wrist  of  A,  arid  then 
with  the  same  pressure  to  the  wrist  of  B,  the  force  exerted  upon 
the  artery  may  be  quite  different  in  the  two  cases  owing  to  the  dif- 
ferent shape  of  the  wrist  in  the  two  individuals. 

Almost  any  type  of  tracing  can  be  obtained  from  a  normal  pulse 
by  varying  the  pressure. 

This  objection  is  fatal  to  the  use  of  the  sphygmographjas  an  in- 
strument of  precision,  and  although  it  is  capable  of  recording  tiny 


Paravertebral 
Trianjrle 


FIG.  241. -Areas  of  Dulness  in  Pleural  Effusion. 

secondary  waves  unpalpable  by  the  fingers,  it  has  yet  to  be  shown 
that  it  reveals  anything  of  practical  diagnostic  value  which  is  not 
appreciated  by  skilled  fingers.  For  these  reasons  I  have  given  no 
account  of  the  instrument  in  the  body  of  this  work.  The  poly- 
graphic  simultaneous  records  of  the  venous  and  arterial  (or  cardiac) 
movements  so  extensively  studied  by  Mackeusie,  Wenkeback,  Cush- 
ny,  and  others,  are  not  referred  to  either  in  this  section  or  elsewhere 
in  this  book  because  I  have  not  yet  had  enough  experience  with 
their  use  to  have  any  personal  opinion  as  to  their  diagnostic  or  prog- 
nostic value. 


538  PHYSICAL  DIAGNOSIS. 


APPENDIX   F. 

THE  PARA  VERTEBRAL  TRIANGULAR  AREA  OF  DULNE8S  IN 
PLEURAL  EFFUSION. 

Koranji  was  the  first  to  point  out  this  sign,  though  it  is  usually 
miscalled  "  Grocco's  siyn."  Over  the  spinal  column  and  on  the 
sound  side  of  the  chest  there  appears  in  most  pleura!  effusions  an 
area  of  dulness  such  as  is  shown  in  Fig.  241.  This  is  due,  pre- 
sumably, to  the  displacement  of  the  mediastinal  tissues.  If  the 
patient  lies  on  the  diseased  side  the  triangular  dulness  disappears 
(as  a  rule)  from  the  other  side  (E wart's  "crucial  test"). 

Subdiaphragmatic  abscess  or  tumor  may  produce  a  similar  area 
of  dulness. 

Opinions  differ  as  to  the  importance  of  the  paravertebral  tri- 
angle in  excluding  solidification  and  solid  tumors.  So  far,  I  have 
not  found  it  of  much  value. 


INDEX. 


ABDOMEN,  contour  of,  365 

distended  and  tortuous  veins  of, 

365 

inspection  of,  364 
marking  of,  365 
methods  of  examination,  364 
organs  palpable  in,  368 
palpation     and     percussion     of, 

364 

palpation,  methods  of,  366 
projection  or  levelling  of  navel, 

365 

respiratory  movements  of,  366 
rose  spots  on,  365 
tumors  of,  370 
tumors  of,  diagnosis  from  tumors 

of  wall,  370 

tumors  of,  observation  of,  370 
tumors  of,   respiratory  mobility 

in,  370 

tumors  of,  with  ascites,  370 
tumors  of,  with  jaundice,  370 
tumors  of,  with  leuksemic  blood, 

370 

Abdominal  reflexes,  516 
wall,  abscess  of,  369 
wall,  actinomycosis  of,  369 
wall,  infected  hsematoma  of,  369 
wall,  sarcoma  of,  369 
wall,  tuberculosis  of,  369 


Abscess,  alveolar,  25 

cervical,  in  Pott's  disease,  31 

cold,  55,  69 

in  tuberculous  arthritis,  494 

ischio-rectal,  443 

of  abdominal  wall,  369 

of  appendix,  psoas  spasm  in,  495 

of  brain,  optic  neuritis  in,  16 

of  glands  near  urethra,  449 

of  hip-joint,  45Z 

of  liver,  354-390 

of  lung,  breath  in,  21 

of  tonsil,  28 

perinephritic,  54,  418 

perinephritic,    psoas    spasm    in, 
495 

peri-urethral,  445 

psoas,  55,  455-457 

diagnosis  from  actinomyco- 
sis, 55 

pulmonary,  359 

retropharyngeal,  28 

tuberculous,  55 
Acetone  breath,  21 
Achilles  reflex,  test  for,  515 

tendon,  tenosynovitis,  463 
Achromia  of  red  cells,  in  chlorosis, 

478 

Achylia   gastrica,   stomach   contents 
in,  382 


539 


540 


INDEX. 


Acid  urine,  425 

Acne,  eruptions  on  forehead  in,  9 

nose  in,  17 
Acromegalia,  8,  9,  40 

chin  in,  10 

face  in,  8,  9 

family  likeness  in,  9 

feet  in,  47 

hands  in,  47 

nose  in,  10,  17 

prominent  cheek  bones  in,  10 

ridges  above  eyes  in,  10 

"whopper-jaw"  in,  10 
Actinomyces  of  belly- wall,  369 
Actinomycosis  of  neck,  34 
Acute  dyspnceic  conditions,  depressed 
fontanels  in,  7 

endocarditis,  527 

fevers,  loss  of  hair  in,  7 
Addison's  disease,  buccal  patches  in, 

26 

Adenitis,  29,  94,  95,  523 
Adenoids,  10 

and  thoracic  deformity,  60 

breathing  in,  11 

face  in,  10,  11 

mouth  in,  10,  18 

nose  in,  17 

snoring  in,  11 

tonsils  in,  28 

Adherent  pericardium,  276 
Agraphia,  518 
Albuminuria,  Esbach's  test  for,  426 

in  local  peritonitis,  373 

in  peritonitis,  373 

significance  of,  427 

test  for,  426 

with  nephritis,  428 

without  nephritis,  427 
Alcoholism,  ataxia  in,  510 

breath  in,  21 


Alcoholism,  coma  in,  521 

distribution  of  fat  in,  12 

exaggerated  pharyngeal  reflex  in, 
29 

face  in,  12 

nose  in,  12,  17 

paralysis  in,  36,  458 

shaking  of  head  in,  13 

tongue  in,  22 

tremor  of  hands  in,  44 

vomiting  in,  29 

with  fatty  liver,  389 
Alkaline  urine,  425 
Alopecia  areata,  patchy  baldness  in, 

7 
Amoeba  coli,  407 

coli,  in  faeces,  407 
Amphoric  breathing,  161,  313,  322 
Amyloid  disease,  spleen  in,  414-416 

liver,  390 

Amyotrophic  lateral  sclerosis,  514 
Anaemia,  ascites  in,  374 

blood  in,  472 

diagnosis  of,  14 

in  cancer  of  peritoneum,  374 

in  cancer  of  stomach,  384 

in   tuberculosis    of    peritoneum, 
374 

oedema  of  eyelids  in,  14 

of  nails,  52 

pernicious,  blood  in,  478 

retinal  haemorrhage  in,  16 

secondary,  blood  in,  477 

secondary,  causes  of,  478 
Anaesthesia,  hysterical,  512 

in  neuritis,  36 

tests  of,  511 
Anatomy  of  chest,  56 
Aneurism,  54,  280-291 

abdominal,  368 

abnormal  pulsation  in,  86, 87, 280 


INDEX. 


541 


Aneurism,  auscultation  in,  285 
diagnosis  of,  288,  289 
diastolic  shock  in,  282 
diffuse,  280,  289 

distinguished  from  aortic  steno- 
sis, 289  - 

distinguished  from  diffuse  dilata- 
tion of  the  arch,  without  rup- 
ture of  coats,  289 
distinguished  from  empyema  ne- 

cessitatis,  290 
distinguished    from    mediastinal 

tumors,  290 
emaciation  in,  2 
percussion  signs  in,  284 
pressure  symptoms  in,  284 
radioscopy  in,  287,  528 
thoracic,  280,  291 
thrill  in,  282 
tracheal  tug  in,  283 
tumor  in,  281 
with  contracted  pupil,  15 
Angioneurotic  local  swellings,  519 
oadema  of  lip,  19,  20 
cedema,  symptoms  of,  14 
Ankle  clonus,  test  for,  515 
epithelioma  of,  463 
jerk,  test  for,  515 
tuberculosis  of,  463 
Ankylosis,  following  atrophic  arthri- 
tis, 499 
Anorexia  in  local  peritonitis,  373 

nervosa,  malnutrition  in,  2 
Anterior  poliomyelitis,  acute  paralysis 

in,  36 
poliomyelitis,      knee  -  jerk      in, 

514 

poliomyelitis,  reaction  of  degen- 
eration in,  518 
Anus,  fissure  of,  443 
fistula  of,  443 


Aorta,  aneurism  of,  pointing  in  back, 
54 

normally  palpable,  368 
Aortic  aneurism,  86,  280 

disease,  229,  246 

obstruction,  see  Stenosis 

pulsation  (dynamic),  86 

regurgitation,  229-239 

regurgitation,    complication    of, 
238 

regurgitation,  diagnosis  of,  237 

regurgitation,  murmurs  in,  235 

regurgitation,  pulse  in,  232,  233 

regurgitation,  signs,  230 

regurgitation,    sounds    in,    236, 
237 

roughening,  238 

second  sound,  179 

stenosis,  239-246 

stenosis,  diagnosis  of,  243-245 

stenosis,  murmurs  in,  240 

stenosis,  pulse  in,  242 

stenosis,  signs  in,  240-246 

stenosis,  thrill,  243 
Apex  beat,  see  Cardiac  Impulse 

cardiac,  see  Heart 

retraction,  84 
Aphasia,  518 
Apncea,  in  Cheyne-Stokes  breathing, 

74 
Apoplexy,  75 

coma  in,  520 

distinguished  from  uraemia,  520 
Appendicitis,  cause  of  peritonitis,  373 

diagnosis  of,  402 

local  and  constitutional  signs  in, 
401,  402 

muscular  spasm  in,  402 

psoas  spasm  in,  495 

simulated,  402 

tumor  in,  402 


INDEX. 


Appendix  in  palpation,  368 
Arcus  senilis,  16 

senilis  in  arteriosclerosis,  16 

senilis  in  old  age,  16 
Argyll-Robertson  pupil,  15 
Arm,  35 

contractures  of,  37 
Arms,  deep  reflexes  of,  516 

fatty  tumors  of,  38 

gouty  deposits  in,  38 

in  Paget's  disease,  40 

in  rickets,  40 

oedema  of,  38 

cedema  of,  in  Hodgkin's  disease, 
38 

cedema  of,  in  inflammation,  38 

cedema  of,  in  nephritis,  38 

cedema  of,  in  sarcoma  of  lung,  3 

cedema  of,  in  sarcoma  of  medias- 
tinum, 38 

cedema  of,  in  thrombosis,  38 

cedema  of,  with  tumors,  38 

paralysis  of,  35 

sarcoma  of  bone  of,  38,  39 

syphilitic  nodes  in  bone  of,  38 

tuberculosis  of  bone  of,  38,  40 

tuberculous  lesions  of,  39 

wasting  of,  37 
Arrhythmia,  263 
Arsenic  poisoning,  neuritis  in,  458 

poisoning  with  conjunctivitis,  14 
Arterial  movements,  89 

murmurs,  198 

pressure,  111-117 

pressure,  diastolic,  108,  116 

pressure,  methods  of  measuring, 
111 

pressure,  systolic,  106,  114 

pulsations,  89 

sclerosis,  90 

sounds,  182 


Arterial  tension,  108,  109,  111 

walls,  calcification  of,  110 
Arteries,  auscultation  of,  237 

calcification  of,  110 

diseases  of,  1 10,  280 

inspection  of,  8& 

murmurs  in,  198,  237 

position  of,  109 

size  of,  109 

stiffening  of,  110 

tuberosity  of,  90 
Arteriosclerosis,  amis  senilis,  16 

gangrene  of  toe  in,  465 

hot  feet  in,  464 

paraesthesia  in,  512 
Arthritis,    acute    infectious,     distin- 
guished from  other  types,  495 

acute  infectious,  endocarditis  in, 
497 

acute  infectious,  results  of,  497 

acute  infectious,  signs  in,  497 

atrophic,  47-50,  496,  498,  499 

atrophic,  changes  in  wrist,  47 

atrophic,  flipper-hand  in,  46,  47 

atrophic,  Morvan's  disease  in,  50 

distinguished  from  acute  osteo- 
myelitis, 456 

dysenteric,  495 

gonorrhceal,  495 

gouty,  503 

hsemophilic,  diagnosis  of,  505 

hypertrophic,  features  of,  500 

hypertrophic,  Heberden's  nodes 
in,  47-50 

hypertrophic,  of  sacro-iliac  joint, 
53 

hypertrophic,    psoas    spasm    in, 
495 

hypertrophic,  with  kyphosis,  54 

infectious,  494 

infectious,  inguinal  glands  in,  455 


INDEX. 


543 


Arthritis,  influenzal,  495 

pneumococcic,  495 

syphilitic,  495 

tuberculous,  494 
Ascaris  lumbricoides,  407-411 
Ascites,  372-374 

Asphyxia,    local,   in   Raynaud's   dis- 
ease, 49 

Astereognosis,  511 
Asthma,  322 

bronchial,  322 

bronchial,  blood  in,  481 

diagnosis  of,  322 
Asthmatic  breathing,  74,  322 
Ataxia,  causes  of,  374 

forms  of,  510 

respiratory  movements  of  belly 
in,  366 

Romberg's  sign  in,  511 
Atelectasis,  66,  73,  163,  361 

crepitant  rales  in,  163 
Athetosis,  45,  510 

Atrophic  arthritis,  ankylosed  stage  in, 
499 

arthritis,  deformities  in,  500 

arthritis,  monarticular  form,  499 

arthritis,  polyarticular  form, 
symmetrical  involvement  of 
joints  in,  499 

arthritis,  primary  polyarticular 
form,  499  , 

arthritis,  types  of,  496,  498,  499 

arthritis,  x-ray  of  hand  in,  496 

diseases  of  wrist-joint,  40 
Atrophy  following  fracture  or  dislo- 
cation, 37 

in  hysteria,  37 

muscular,  claw-hand  in,  46 

of  disuse,  37 

progressive  muscular,  fibrillary 
twitching  in,  510 


Atrophy,       progressive        muscular, 

wasting  of  arm  in,  37 
trophic,  37 

Auscultation,     137,    198.     (See    also 
Breathing       and       Murmurs. 
Rales.     Heart  sounds.) 
mediate  vs.  immediate,  137,  138 
of  heart,  171,  198 
of  lungs,  149-170 
of  muscle  sounds,  146 
sources  of  error  in,  146-149 
technique  of,  143-146 

BABINKSKI'S   reaction,    in   paralysis, 
520 

reflex,  test  for,  516 
Back,  53,  66 

aneurism  pointing  in,  54 

dermoid  cyst  of,  55 

epithelioma  of,  55 

in  lumbago,  53 

lipomata  of,  55 

perinephritic  abscess  of,  54 

spina  bifida  of,  55 

stiffness  of,  53 

tumors  of,  54 

Bacteria  in  faeces,  method  of  exami- 
nation for,  406 
Balanitis,  445 
Balantidium  coli,  407 
Baldness,  hereditary,  7 

in  trigeminal  neuralgia,  7 

patchy,  in  alopecia  areata,  7 

patchy,  in  skin  disease,  7 
Barrel  chest,  64,  318 
Baths,  cold,  leucocytosis  in,  480 
Belly,  in  cretinism,  10 

in  general  peritonitis,  37 

wall,  hernia  in,  369 

wall,  lesions  of,  369 
Biceps,  rupture  of,  38 


544 


INDEX. 


Bile  in  blood,  14 

in  urine,  14 
Bile-ducts,  395 
Bilharzia  disease,  blood  in,  481 

haematobium,  407-412 
Biliary  colic,  419 

colic,  differential  diagnosis  of,  395 

obstruction,  14 
Bladder  data,  439 

diseases  of,  urine  in,  441 

distention  of,  439 

distention  of,  causes  of,  440 

paralysis  of,  retention  of  urine  in, 
441 

statistics  on,  439 

stone  of,  441 

tuberculosis  of,  442 

tumors  of,  retention  of  urine  in, 
441 

tumors  of,  urine  in,  425 
Blindness,  dilatation  of  pupil  in,  15 
Blood,  appearance  when  stained,  471 

coagulation  time  in,  487 

color  index  of,  468 

counting  red  corpuscles,  method 
of,  476 

counting  white  corpuscles,  meth- 
od of,  475 

cover-glass  preparation  of,  470 

eosinophilia  in,  480 

examination  of,  466 

examination  of  stained,  469 

haemoglobin  tests,  466-468 

in  chlorosis,  478 

in  faeces,  405-406 
,  in  lymphatic  leukaemia,  481 

in  pernicious  anaemia,  478 

in  secondary  anaemia,  477 

interpretation  of  result  of  leu- 
cocyte count  and  differential 
count,  479 


Blood,  in  vomitus  in  gastric  cancer, 
384 

in  whooping-cough,  481 

leucocytes  in,  473 
•    leucocytosis  in,  480 

lymphocytosis  in,  480 

normoblasts   distinguished  from 
megaloblasts  in,  472 

nucleated  red  cells  in,  472 

parasites  in,  484 

percentages  of  white  cells  in,  473 

platelets  in,  474 

poikilocytosis,  472-477 

polychromasia,  472-477 

preparation    of    film,    spreading, 
469 

pressure,  see  Pressure 

staining  of,  469 

stains  used,  471 

stippled  red  cells  in,  472 

test  for,  381 

Widal  reaction,  483 
Body,  as  a  whole,  1 

fluid  in,  1 

weight  of,  1 
Bone,     destruction     of,   in    atrophic 

arthritis,  498 
Bones  in  acromegalia,  10 
Bony  nodes  of  forehead,  8 
Bow-legs,  460 
Bradycardia,  262 
Brain,  abscess  of,  optic  neuritis  in,  16 

diseases  of,  transient  glucosuria 

in,  429 
,  lesions  of,  hemianaesthesia  in,  512 

paralysis  of,  508 

paralysis  of,  mental  changes  in, 
509 

tumors  of,  optic  neuritis  in,  16 
Branchial  cyst,  33,  34 

fistulae,  congenital,  34 


INDEX. 


545 


Breast,  funnel,  62 

pigeon,  62,  65  (see  also  Chest) 
Breath,  acetone,  21 

foul,  21 

in  alcoholism,  21 

in  foul  teeth  and  gums,  21 

in  gastric  fermentation,  21 

in  poisoning  by  illuminating  gas, 
22 

in  starvation,  21 

in  stomatitis,  21 

in  syphilis,  21 

in  typhoid  fever,  21 

in  uraemia,  21 
Breathing,  amphoric,  161 

asthmatic,  69,  74,  155 

bronchial,  153,  160 

bronchovesicular,  160 

catchy,  75 

cavernous,  161 

Cheyne-Stokes,  74 

Cheyne-Stokes,   causes  of,   75 

cogwheel,  156 

compensatory,  157 

costal,  69 

diaphragmatic,  69 

difficult,  71 

diminished,  71 

emphysematous,  155 

exaggerated  vesicular,  153,  157 

grunting,  75 

interrupted,  156 

irregular,  75 

metamorphosing,  156 

normal,  69,  72 

puerile,  153 

rapid.  71.  72 

restrained,  75 

rough, 153 

shallow,  75 

sighing,  76 
35 


Breathing,  stertorous,  75 

stridulous,  74,  76 

tracheal,  153,  154,  160 

tubular,  153,  160 

types  of,  74 

vesicular,  151 

(see  also  Respiration) 
Brodie  Russell  coagulometer,  486 
Bronchi,  dilatation  of  (see  Bronchiec- 
tasis) 

diseases  of,  292,  296,  322-324 

stenosis  of,  525 
Bronchial  asthma,  294,  320,  322 

breathing  (see  Breathing) 
Bronchiectasis,  323 
Bronchitis,  292 

acute,  292 

chronic,  40,  47,  295,  320 

diagnosis,  294 
Bronchophony,  168 
Bronchopneumonia,  303 
Bronchovesicular,  160  (see  Breathing) 
Buccal  cavity,  25 

cavity,  gangrene  of,  26 

cavity,  in  Addison's  disease,  26 

cavity,  pigmentations  in,  26 
Bulging  of  interspaces,  68 

of  one  chest,  68 
Bursitis  of  prepatellar  bursa,  460 

"CACHEXIA"  of  old  age,  2 
Calcaneus,  462 
Calculus,  biliary,  393 
Cancer,  gastric,  2 

gastric,     advanced,     symptoms, 
384 

gastric,  malnutrition  in,  2 

gastric,  statistics  of,  384 

gastric,  tumor  in,  377 

gastric,  with  absence  of  hydro- 
chloric acid.  384 


546 


INDEX. 


Cancer,  metastatic,  of  thigh,  457 

metastatic,  with  pressure  on 
cord,  paraplegia  in,  459 

obstruction  of  gall-duct  in,  396 

of  chest  wall,  360 

of  intestines,  signs  and  symptoms 
of,  404 

of  liver,  389 

of  lung,  67,  360 

of  pancreas,  jaundice  in,  396-397 

of  penis,  446 

of  peritoneum,  372-374 

of  peritoneum,  anaemia  in,  374 

of  peritoneum,  ascites  in,  374 

of  peritoneum,  diagnosis  of,  374 

of  peritoneum,  emaciation  in,  374 

of  peritoneum,  signs  of,  374 

of  peritoneum,  tumors  in,  374 

of  pleura,  355-360 

of  rectum,  444 

of  sigmoid,  404 

of  testis,  446 

of  thyroid  gland,  32 

of  tongue,  22 

of  uterus,  450 

with    enlarged    cervical    glands, 

30 

Canker  of  tongue,  22 
Capillary  pulse,  52,  91,  232 
Cardiac  disease,  ascites  in,  374  (see 
also  Heart) 

disease,  diuresis  in,  1 

disease,  dropsy  in,  1 

disease,  sweating  in,  1 

disease,  weight  in,  1 

hypertrophy  (see  Hypertrophy) 

impulse,  character  of,  79 

impulse,  displacement  of,  66,  79, 
203,  205,  208,  210,  231,  243, 
277,  334,  343 

impulse,  normal,  79 


Cardiac     murmurs,      184-198      (tee 

Murmurs) 

movements,  203,  257,  261-265 
neuroses,  261-265 
neurosis,  arrhythmia  in,  263 
neurosis,  bradycardia  in,  262 
neurosis,  palpitation  in,  264 
neurosis,  tachycardia  in,  261 
outlines,  57, 205-208,  531 
sounds,  172 

Caries  of  vertebra?,  abscess  in,  28 

Carphologia,  43 

Cartilage,  destruction  of,  in  atrophic 
arthritis,  498 

Casts  in  urine,  431 

Cavernous  breathing,  313 

Cavity,  pulmonary,  313 

Cervical  rib,  an  accessory,  34 

Chancre  of  lip,  19 

Chancroids,  inguinal  glands  in,  454 

Charcot's  joint,  atrophic  arthritis  in, 

498 
joint,  motility  in,  493 

Cheek  bones  in  acromegalia,  10 

Chest,  anatomy  of,  56 

auscultation  of,  137-170 
barrel-shaped,  64 
deficient  expansion,  70 
deformities,  60,  64,  66 
examination  of,  60,  361 
examination  of,  in  infancy,  528 
expansion,  anomalies  of,  69 
expansion,  diminished,  70 
expansion,  "en  cuirasse,"  74 
expansion,  increased,  71 
flattening  of,  66 
fluctuation  in,  352 
fluoroscopic,  529 
in  adenoid  disease,  60 
inspection  of,  60 
landmarks  of,  56,  66 


INDEX. 


547 


Chest,  local  depression,  61,  62 

local  prominences,  67 

movements  of,  69-76 

palpation  of,  96-103 

phthisical,  63,  67,  304-316 

prominence,  local,  68 

prominence  of  one  side,  67 

rachitic,  6d,  62,  63 

radioscopy  of,  352 

retraction  of,  73 

shape  of,  61-66 

size  of,  60 

surface  of,  91-36 

tenderness  in,  102 

wall,  cancer  of,  360 

wall,  nutrition  of,  65,  93 
Cheyne-Stokes  breathing,  75 
Chickenpox,  throat  in,  27 
Chilliness,  diagnosis  from  chill,  4 
Chills,  3,  4 

after  infusion  of  salt  solution,  4 

after  or  during  labor,  3 

after  passage  of  catheter.  3 

determination  of  etiology,  4 

diagnosis  from  chilliness,  4 

of  acute  infections,  3 

of  malaria,  3 

of  "nervous"  states  3 

of  sepsis,  3 

Chin  in  acromegalia,  10 
Chlorosis,  blood  in,  478 
Cholangitis,  suppurative,  390 

symptoms  in,  394 
Cholecystitis,  cause  of  peritonitis,  373 

results  of,  397 

signs  of,  396 
Chorea,  13 

leg  in,  459 

post-hemiplegic,  45 

spasm  in,  13 

Sydenham's,  of  hands,  44 


Choreiform  movements,  510 
Circulation,    portal,    obstruction    of, 

365 
Cirrhosis  of  liver,  389 

of    liver,    abdominal    veins    in, 
365 

of  liver,  spleen  in,  414-415 

of    liver,    toxaemia    in,    distin- 
guished from  uraemia,  520 

of  lung,  83,  315,  324 
Claudication,  intermittent,  458 
Clavicles,  prominence  of,  63,  65 
Claw-hand,  46 

in  chronic  poliomyelitis,  46 

in    paralysis    of    interossei    and 
lumbricales,  46 

in  progressive  muscular  atrophy, 
46 

in  syringomyelia,  46 
Cleft  palate,  20 
Club-foot,  varieties  of,  462 
Cog-wheel  breathing,  156 
Cold  sore,  18,  19,  519 

tremor  of  hands  in,  43 
Colic,  biliary,  419 

in  gall-stone  impaction,  395 

in  plumbism,  396 

intestinal,  420 

renal,  395-419 
Collapsed  states,  depressed  fontanels 

in,  7 
Colon,  fluid  in,  palpation  of,  368 

inflation  of,  in  diagnosis  of  ab- 
dominal tumors,  370-372 
Coma,  519 

causes  of,  519 

determination  of  hemiplegia  in, 
520 

dilatation  of  pupil  in,  15 

knee-jerk  in,  514 

sphincteric  reflexes  in,  517 


548 


INDEX. 


Compensation,  cardiac,  establishment 

and  failure  of,  202-205 
Compression,  coma  in,  symptoms  in, 

521 

of  lungs,  66 

Concussion,  coma  in,  521 
Congenital  heart  disease,  265 

spastic  paralysis,  gait  in,  508 
Congestion,  hypostatic,  362 
Conjunctivitis,  14 

distinguished  from  iritis,  14 
from  overdose  of  arsenic,  14 
from  overdose  of  iodide  of  pot- 
ash, 14 

with  hay-fever,  14 
with  influenza,  14 
with  measles,  14 
with  yellow  fever,  14 
Consciousness,  loss  of,  519 
Constipation     in     local    peritonitis, 

373 

tongue  in,  22 

Contagion,  psychic,  choreiform  move- 
ments in,  45 

Contractures  following  atrophic  ar- 
thritis, 499 

hemiplegic,  hand  in,  46 
of  arm,  37 
of  the  interossei  and  lumbricales, 

claw-hand  in,  46 
Cord,  compression  of,  anaesthesia  in, 

512 

lesions  of,  knee-jerks  in,  515 
paralysis,  508 
paralysis  of,  disorders  of  bladder 

and  rectum  in,  509 
Cornea,  16 
Costal  angle,  64 
Cough, 165,  306 
Cramp,  spasm  in,  510 
Cranial-nerve  paralysis,  508 


Cranium,  5 

size  and  shape,  5 
Cremasteric  reflex,  516 
Crepitus    in    monarticular    atrophio 
arthritis,  499 

in  perigastritis,  371 

in  perihepatitis,  371 

in  perisplenitis,  3J1 

in  peritonitis,  371 

peritoneal,  371 
Cretinism,  10 

deformed  legs  in,  10 

delayed  closure  of  fontanels  in,  6 

face  in,  10 

lips  in,  18-20 

mouth  in,  18-20 

pot-belly  in,  10 

teeth  in,  20 

tongue  in,  24 
Croup,  76 

Curvature  of  spine,  66,  70,  71 
Cyanosis,  92,  265 

of  nails,  52 
Cyst,  branchial,  33,  34 

dermoid,  of  back,  55 

of  ovary,  451-452 
Cystitis,  symptoms  in,  425 

urine  in,  425,  437,  441 

with  frequent  micturition,  441 
Cystocele,  448 
Cystoscopy,  442 
Cyto-diagnosis,  355-358 

of  pleural  effusion,  356 

technique  of,  356 

DEBILITY,  fibrillary  twitching  in,  510 

spleen  in,  415 
Deformities,  congenital,  of  heart,  265 

of  chest,  62-73 

of  hands,  46 
Degeneration,  reaction  of,  517 


INDEX. 


Dementia  paralytica,  degeneration  of 
handwriting  in,  518 

paralytica,  reaction  of  pupil  in, 
15 

paralytica,  sexual  power  in,  517 

paralytica,    sphincteric    reflexes 
in,  517 

paralytica,  tongue  in,  22 
Dermatitis,  resulting  from  pediculi,  8 
Dextrocardia,  84 
Diabetes,  acetonaemia  in,  430 

breath  in,  21 

bronzed,  398  . 

coma  in,  signs  in,  521 

dyspnoea  in,  72 

malnutrition  in,  2 

mellitus,  429 

mellitus,  gangrene  of  toe  in,  465 

optic  neuritis  in,  16 
.  retinal  hemorrhage  in ,  16 

ulcer  of  toe  in,  465 
Diaphragm,  69 

movements  of,  69,  74,  76 

paralysis  of,  71 
Diarrhoaa,  causes  of,  401 

depressed  fontanels  in,  6 

malnutrition  in  chronic,  2 
Diastolic  murmur  (see  Murmur) 

shock,  282 

Dibothriocephalus  latus,  407-411 
Dietl  s  crisis   420 
Digestion,  painful   with  hyperacidity, 

385 

Dilatation  cardiac,  205,  208,  291 
Diphtheria,  larynx  in,  26 

neuritis  due  to,  458 

tonsils  in,  26 

with  enlarged  glands,  30 

with  nasal  discharge,  17 
Displacement  of  cardiac  impulse,  82 
(see  also  Cardiac} 


Distention,  flatulent,  400 
Distentions    following    atrophic    ar- 
thritis, 499 
Dropsy,  evident,  1 

in  cardiac  disease,  1 

in  renal  disease,  1 

increase  of  weight  in,  1 

latent,  1 
Ductus    arteriosus,    persistence    of, 

266 

Dulness  on  percussion,  130 
Dupuytren's  contraction,  51 
Dysentery,  arthritis  in,  495 

chronic,  anaemia  in,  478 
Dyspepsia,  malnutrition  in  chronic,  2 

statistics  of,  384 

Dyspnoea,  71,  74,  523  (see  also  Breath- 
ing) 

causes  of,  72 

nose  in,  17 

mouth  in,  18 

varieties  of,  72 
Dystrophy,  muscular,  lordosis  in,  54 

EAR,  gouty  tophi  of,  505 
Egophony,  169,  299,  346 
Electrical  reactions,  517 
Emaciation,  2,  374-394 
Emphysema,  60,  67,  317-322 

atrophic  (or  small-lunged),  317 

barrel  chest  in,  60,  67,  318 

breath  sounds  in,  319 

complementary,  321 

complications  of,  320 

diagnosis  of,  319 

interstitial,  321 

large-lunged,  317 

neck  in,  29 

percussion  signs  in,  318 

radioscopy  in,  535 

senile,  317 


550 


INDEX. 


Emphysema,  subcutaneous,  321  (see 
Interstitial) 

with  asthma,  320 

with  bronchitis,  320 

with  kyphosis,  54 

with  tuberculosis,  315 
Empyema,  346,  352-353,  354 

necessitate,  69,  290,  352 

with    hypertrophic    osteoarthri- 

tis,  40,  47 
Endocarditis,  acute,  213,  251,  527 

chronic,  213-258 

in  acute  infectious  arthritis,  497 
Endometritis,  450 
Eosinophile  cells  in  blood,  473 
Eosinophilia,  481 
Epididymitis,  446 
Epigastric  pain,  376 

pulsations,  85,  276 

reflexes,  516 

retraction,  84 

tumor,  377-384 
Epigastrium,  hernia  in,  377 

inspection  and  palpation  of,  376 

tumor  of,  377 
Epilepsy,  local  paraesthesia  in,  512 

scars  on  forehead  in,  8 

spasms  in,  510 

Epiphyses,  enlarged,  in  rickets,  463 
Epiphysitis,  acute  septic,  455 

acute  septic,  diagnosis  from  ar- 
thritis, 486 

chronic  tuberculous,  456 
Epispadias,  445 
Epithelioma  of  ankle,  463 

of  back,  55 

of  hip,  19 

of  nose,  17 

of  thigh,  457 
Epulis,  25 
Equinus,  462 


Eruptions  on  forehead,  8,  9 
Erysipelas,  oedema  of  eyelids  in,  14 

symptoms  of,  14 
Erythromelalgia,  464 
Ewald's  test  meal,  381 
Exophthalmic  goitre,  11,  12,  31 

goitre,  glucosuria  in,  429 
Exostosis  of  thigh,  456 
Eyelashes  in  phthisis,  12 
Eyelids,  dropping  of,  16 

oedema  of,  13,  14 
Eyes,  13,  14 

in  Graves'  disease,  11,  12 

in  hydrocephalus,  5 

in  jaundice,  14 

in  muscle  paralysis,  508 

in  phthisis,  12 

FACE,  5,  9 

after  vomiting,  12 

in  acromegalia,  8,  9 

in  adenoids,  10,  11 

in  alcoholism,  12 

in  chronic  diffuse  nephritis,  12 

in  cretinism,  10 

in  exophthalmic  goitre,  11,  12 

in  general  peritonitis,  12,  374 

in  Graves'  disease,  11,  12 

in  heart  disease,  12 

in  intestinal  obstruction,  12 

in  leprosy,  11,  12 

in  myxoedema,  10 

in  nephritis,  12 

in  paralysis  agitans,  1 1 

movements  of,  13 

oedematous,  12 

spasms  of,  13 
Fallopian  tubes,  450 
Faradic  reaction  in  disease.  518 
Fat,   distribution   of,   in  alcoholisrn, 
12 


INDEX. 


551 


Fatigue,  degeneration  of  handwriting 

in,  518 

Fatty  metamorphosis  of  heart,  260 
Febrile  disease,  bulging  fontanels  in,  6 
Feces,  abnormal  ingredients  in,  405 

bacteria  in,  method  of  examina- 
tion for,  406 

blood  in,  405-406 

color  of,  404 

examination  of,  404 

gall-stones  in,  406 

microscopic  examination  of,  tech- 
nique, 410 

mucus  in,  405 

odor  of,  405 

parasites  in,  eggs,  diagnosis  of, 
408-409 

parasites  in,  types  of,  406 

pus  in,  406 

tissue  shreds  in,  406 

weight  of,  404 

Feet,  hot,  in  myocarditis,  in  arterio- 
sclerosis, 464 

in  acromegalia,  47 
Fermentation  in  cancer  of  stomach, 

384 
Fever,  continued,  3 

crisis  in,  3 

determination  of,  3 

dilatation  of  pupils  in,  15 

emaciation  in,  2 

in  atropinism,  3 

infectious,  3 

infectious,  glucosuria  in,  429 

in  inflammations,  3 

in  nervous  excitement,  3 

in  pneumonia,  3  '* 

in  "septic"  conditions,  3 

in  sunstroke,  3 

intermittent,  3 

in  toxic  states,  3 


Fever,  in  tuberculosis,  3 

in  typhoid,  3 

lysis  in,  3 

nosebleed  in,  17 

peritonitis,  373 

tremor  of  hands  in,  43 

types  of,  3 

Fibrillary  twitching,  510 
Filariasis,  blood  in,  481 

parasites  in,  485-486 
Fingers,  clubbed,  47-49 

in  heart  disease,  47-49 

in  lung  disease,  47-49 

in  pleural  disease,  47-49 
Fistulse,  branchial,  congenital,  34 
Fixation  of  costo-vertebral  joints,  74 
Flat-foot,  462-463 
Flattening  of  one  chest,  66 
Flipper-hand    in    atrophic    arthritis, 

46,  47 
Fluid,  free,  in  abdomen,  tests  for,  371 

free,  in  ascites,  371 

free,  in  haemoperitoneum,  371 

free,  in  peritonitis,  371 

free,  in  ruptured  cyst,  371 
Fluoroscope,  use  of,  529 
Flush  in  phthisis,  12 
Follicular  tonsillitis,  27 
Fontanels,  6 

bulging  of,  6 

delayed  closure  of,  6 

depression  of,  6 

time  of  closing  of,  6 
Forehead, 8 

bony  nodes  of,  8,  9 

eruptions  of,  8,  9 

eruptions  of,  differential  diagno- 
sis in,  9 

scars  of,  8 
Fremitus,  tactile,  98 

tactile,  in  emphysema,  320 


552 


INDEX. 


Fremitus,  tactile,  in  pleural  thicken- 
ing, 351 

tactile,  in  pleuritic  effusion,  350 
tactile,  in  pneumonia,  297 
tactile,  in  pneumothorax,  331 
tactile,  in  pulmonary  tuberculo- 
sis, 308,  311 
vocal,  167-169  (see  also  Vocal) 

Friction,  pericardial,  100,  268 
peritoneal,  371 
pleural,  100,  165,  337 

Frontal  bone  syphilis,  8,  9 

Funnel  breast,  62 

GAIT,  ataxic,  508 

in  paralysis  agitans,  508 

in  toe-drop,  508 

spastic,  508 
Gall-bladder,  395 

adhesions  about,  397 

and  bile-ducts,  statistics  on,  387 

enlarged,  397 

enlargement  of,  396 

enlargement  of,  causes,  396 
Gall-duct,  common,  obstruction  of,  by 
stones,  394 

stones,  396 
Gall-ducts,  395 
Gall-stone  in  intestinal  obstruction, 

397 
Gall-stones,  393 

in  feces,  406 

Galvanic  reaction  in  disease,  518 
Ganglion,  41 
Gangrene,  causes  of,  465 

local,  in  Raynaud's  disease,  49 

of  buccal  cavity,  26 

of  lung,  359 

of  lung,  breath  in,  21 

Raynaud's  form  of,  519 

toe  in,  465 


Gas,  poisoning  by,  coma  in,  522 
Gastric  cancer,  tumor  in,  diagnosis  of, 

377 

contents,  tests  of,  382 
dilatation,  385 
dilatation,  malnutrition  in,  2 
diseases,  incidence  and  diagnosis 

of,  384 

fermentation,  breath  in*  22 
fermentation,  tongue  in,  22 
hemorrhage,  with  ulcer,  385 
peristalsis,  377 

peristalsis    in    adhesions  of  py- 
lorus, 377 
peristalsis  in  cancer  of  pylorus, 

377 
peristalsis  in  cicatrix  of  pylorus, 

377 
peristalsis  in  muscular  spasm  of 

pylorus,  377 
peristalsis    in  simple  thickening 

of  pylorus,  377 
stasis  in  disease,  386 
stasis,  subjective  symptoms  in, 

386 

ulcer,  385 

ulcer,  malnutrition  in,  2 
ulcer,  tongue  in,  22 
ulcer,  vomitus  with  bright  blood 

in,  385 

General  peritonitis,  face  in,  12 
Genitals,  female,  447 

female,  diseases  of,  blood  in,  481 
female,  inspection  of,  448 
female,  lesions  of,  448 
female,  methods  of  examination, 

447 

female,  palpation  of,  448 
male,  444 

German  measles,  glands  in,  30 
Glands  (see  also  Adenitis) 


INDEX. 


553 


Glands,  cervical,  30 

cervical,  in  malignant  disease,  30 

cervical,  in  tuberculosis,  30 

enlarged,  in  mesentery,  375 

in  cankers,  30 

in  caries  of  the  teeth,  30 

in  diphtheria,  30 

in  German  measles,  30 

in  Hodgkin's  disease,  30 

in  lymphatic  leukaemia,  30 

in  the  exanthemata,  30 

in  tonsillitis,  30 

inguinal,  enlarged  when,  454 

of  neck  in  syphilis,  30 
Glottis,  obstruction  of,  73,  76 
Glucosuria  and  its  significance,  428 

experimental,  429 

transient,  429 
Goitre,  simple,  31,  32 

with  exophthalmus,  11,  12,  31 
Gonorrhoea,  arthritis  in,  495 

balanitis  in,  445 

distended   bladder   in   spasm   of 
urethra  in,  440 

inguinal  glands  in,  454 

orchitis  in,  446 

with  epididymitis,  446 

with  frequent  micturition,  441 
Gout,  arthritis  in,  503 

toe  in,  465 

tophi,  diagnosis  of,  505 

tophi  in  tendon  in,  40 

tophi  in,  test  for,  490 
Gouty  arthritis,  503-505 

arthritis,  destruction  of  bone  in, 
505 

arthritis,  x-ray  of  hand  in,  506 
Graves'  disease,  11,  12,  31 

disease,  eyes  in,  11,  12 

disease,  face  in,  11,  12 

disease,  hands  in,  42 


Graves'  disease,  tremor  of  hands  in, 

44 
Groin,  454 

glands  in,  454 

hernia  of,  455 

hydrocele  of  cord  in,  455 

psoas  abscess  in,  455 
Gumboil,  25 
Gums,  24 

hemorrhage  of,  25 

in  debilitated  states,  25 

in  lead-poisoning,  24 

in  poisoning  by  mercury,  25 

in  poisoning  by  potassic  iodide, 
25 

in  scurvy,  25 

lead  line  in,  24 

sordes  of,  25 

spongy,  25 

suppuration  of,  25 
Gunzburg's  reagent,  382 

H.EMADYNAMOMETER,  Oliver's,    116 

Haematemesis,  in  portal  obstruction, 

392 

Hsematocele,  447 
Hsematoma,  infected,   of  belly- wall, 

369 

Hsematuria,  causes  of,  424 
Haemin  test,  381 
Haemoglobin,  tests  for,  466-468 
Haemopericardium,  272 
Haemophilia,  nosebleed  in,  17 
Haemophilic  arthritis,  505 
Hemorrhage,  pulmonary,  305 
Hair,  7 

general  loss  of,  7 

in  acute  fevers,  7 

in  myxosdema,  8,  10 

in  phthisis,  12 

in  syphilis,  7 


554 


INDEX. 


Hair,  nits  in,  8  - 

normal  loss  of,  7 

pediculi  in,  8 

rubbing  off  of  head  in  rickets,  7 
Hand  in  acromegalia,  47 
Hands,  choreiform  movements  of,  44 

deformities'  of,  46 

evidence  of  occupation,  41 

examination  of,  42 

in  atrophic  arthritis,  46,  47 

in  chronic  poliomyelitis,  46 

in  contractures  following  hemi- 
plegia,  46 

in  Graves'  disease,^^ 

in  myxredema,  46—48 

in  paralysis  of  median  or  ulnar 
nerves,  46 

in  progressive  muscular  atrophy, 
46 

in  syringomyelia,  46 

moisture  of,  42 

movements  of,  42 

professional  spasm  of,  44 

spasms  of,  44 

temperature  of,  42 

tremor  of,  43 

tremor  of,  causes,  43 

tremor  of,  in  alcoholism,  44 

tremor  of,  in  cold,  43 

tremor  of,  in  fever,  43 

tremor  of,  in  Graves'  disease,  44 

tremor  of,  in  hysteria,  44 

tremor  of,  in  multiple  sclerosis, 
44 

tremor  of,  in  nervousness,  43 

tremor  of,  in  old  age,  43 

tremor  of,  in  paralysis  agitans, 
44 

tremor  of,  in  toxaemia,  43 

tremor  of.  test  for,  43 
Handwriting,  degeneration  of,  518 


Hang-nails,  52 

Hare-lip,  20 

Harrison's  groove,  62 

Hay  fever  with  conjunctivitis,  14 

Head,  5 

abnormalities  of,  5 

in  hydrocephalus,  5 

in  idiocy,  5 

in  rickets,  6 

movements  of,  13 

open  areas,  5 

shaking  of,  13 

shaking  of,  in  alcoholics,  13 

shaking  of,  in  morphinism,  13 

shaking  of,  in  poisoning  by  to- 
bacco, 13 

shaking  of,  in  toxic  conditions,  13 

sweating  of,  7 
Heart,  171-267 

action  of,  203,  257,  261-265 

apex,  position,  97 

apex,  impulse,  79,  82,  96 

apex,  retraction,  84 

area,  changes  in,  132 

area,  in  pericarditis,  272 

area,  normal,  129 

arrhythmia  of,  263 

auscultation  of,  171 

bradycardia,  262 

congenital  malformations  of,  265 

dilatation  of,  208-210,  231 

diseases  of,  199-267 

enlargement  of  (see  Hypertrophy) 

examination  of,  171-199 

fatty  metamorphosis,  260 

hypertrophy   of,    203,    205-208, 
210,231,  243,277 

hypertrophy,  causes  of,  205 

impulse,  79,  82 

impulse,  absence  of,  274 

impulse,  displacement  of,  82 


INDEX. 


555 


Heart,  impulse,  modification  of,  96 
in  aortic  regurgitation,  229-239 
in  aortic  stenosis,  239-246 
in  mitral  regurgitation,  210-220 
in  mitral  stenosis,  220-229 
in  myocarditis  (acute),  257 
in  neurosis  of  (chronic),  258 
in  pericarditis,  268,  274,  276 
in  pleural  adhesions,  83,  351 
in  pl°ural  effusion,  343 
in  pneumothorax,  331 
in  pulmonary  regurgitation,  251 
in  pulmonary  stenosis,  252,  265 
inspection  of,  79-86 
irregular  action  of,  263  (see  also 

Arrhythmia) 
lips  in  disease  of,  18 
murmurs,     184-199     (see     also 

Murmurs') 
outlines  of,  128 
palpation  of,  96 
palpitation    of,    264    (see    also 

Arrhythmia') 

parietal  diseases  of,  257-261 
percussion  of,  129 
rapidity  of  (see  Tachycardia) 
situs  inversus,  345 
slow  (see  Bradycardia) 
sounds,  abnormalities  of,  172 
sounds,  accentuation  of,  178,  179 
sounds,  character  of,  172 
sounds,  doubling  of,  176,  181 
sounds,    intensification    of,    175, 

178-179 

sounds,  metallic,  174,  182 
sounds,  modifications  of,  174 
sounds,  muffling  of,  182 
sounds,  normal,  172 
sounds,  position  of,  171 
sounds,  qualities  of,  173 
sounds,  reduplication  of,  176,  181 


Heart  sounds,  rhythm  of,  181 

sounds,  shortening  of,  209 

sounds,  weakening  of,  175,  179 

tachycardia,  261 

temperature,  3 

tricuspid  regurgitation,  246 

tricuspid  stenosis,  250 

uncompensated,  3 

valves,  position  of,  171 

valvular  lesions,  combined,  253 

valvular  lesions  of,  199 

weakness,  258 

(See  also  Cardiac) 
Heberden's  nodes,  47,  50,  500 
Hemiansesthesia,  512 
Hemiplegia,  508 

athetosis  in,  45 

atrophy  of  disuse  in,  37 

changes  of  nails  in,  52 

determination    of,    in    comatose 
state,  520 

paralysis  of  leg  in,  458 

tongue  in,  22 
Hemiplegic  hand,  following  contrac- 

tures,  46 
Hemorrhage,  anaemia  in,  478 

bulging  fontanels  in,  6 

in  retina,  16 

tendency  of,  in  jaundice,  393 
Hemorrhoids,  443 
Hepatic  abscess,  symptoms  in,  394 
.Hernia,  epigastric,  369,  377 

of  groin,  455 

of  scrotum,  447 

umbilical,  369 
Herpes  labialis,  18,  19,  519 

tongue  with,  22 

zoster,  519 

Herpetic  stomatitis,  19 
Hip-joint,   hypertrophic  arthritis  of, 
500 


556 


INDEX. 


Hip-joint,    limitation   of  motion   in, 
494 

Hodgkin's  disease,  glands  in,  30,  375 
disease,  inguinal  glands  in,  455 
disease,  redema  of  arm  in,  38 
disease,  spleen  in,  4J4-416 

Housemaid's  knee,  diagnosis  of,  460 

Hydafid  disease,  blood  in,  481 

Hydrocele,  446 

Hydrocephalus,  5 

bulging  of  fontanels  in,  6 
delayed  closure  of  fontanels  in,  6 

Hydrochloric  acid,  absence  of,  in  can- 
cer of  stomach,  384 

Hydronephrosis,  417 

Hydropericardium,  272 

Hydrothorax,  330 

Hymen,  imperf orate,  448 

Hyperacidity,  gastric,  385 
painful  digestion  in,  385 

Hypersesthesia,  tests  of,  512 

Hyperchlorhydria  (see  Hyperacidity), 
pain  in,  395 

Hypertrophic  arthritis,   features   of, 

500 

arthritis,  hip-joint  in,  500 
arthritis,  kyphosis  in,  54 
arthritis,  limitation  of  motion  in, 

503-504 

arthritis,  nerve  pain  in,  503 
arthritis,  psoas  spasm  in,  495 
arthritis,  signs  in,  500 
arthritis,  spine  in,  501,  502,  503, 
504 

Hypertrophy,  cardiac,  203,  205,  208, 

210,  231,  233,  277 
of  lung,  67 

Hypoacidity,  stomach  trouble,  385 

Hypochlorhydria  (see  Hypoacidity) 

Hypospadias,  445 

Hypostatic  congestion,  362 


Hysteria,  anaesthesia  in,  512 
atrophy  in,  37 

choreiform  movements  in,  45 
coma  in,  521 
hemiansesthesia  in,  512 
hypersesthesia  in,  512 
paralysis  in,  36,  458,  508 
ptosis  in,  16 
spasm  in,  13 
tremor  of  hands  in,  44 

IDIOCY,  mouth  in,  18 
Impulse,  cardiac  (see  Cardiac) 
Incidence  of  diseases  of  the  bladder, 
439 

of  diseases  of  the  intestine,  399 

of  diseases  of  the  kidney,  416 

of  diseases  of  the  liver,  386 

of  diseases  of  the  pancreas,  398 

of  diseases  of  the  stomach,  384 
Indicanuria,  399 
Infancy,  examination  of  chest  in,  522 

jaundice  in,  15 

Infantile  atrophy,  malnutrition  in,  2 
Infections,  acute,  arthritis  in,  495 

acute,  chills  in,  3 

arthritis  in,  494 

crippled  joints  in,  497 

fever  in,  3 

leucocytosis  in,  480 
Inflammation,  oadema  of  arm  in,  38 
Influenza,  arthritis  in,  495 

with  conjunctivitis,  14 

with  nasal  discharge,  17 
Insomnia,  2 

emaciation  due  to,  2 

in  painful  diseases,  2 
Inspection   of  normal    thoracic   pul 
sations,  82-87 

of  apex  beat,  79 

of  cardiac  movements,  79 


INDEX. 


557 


Inspection  of  deformities  of  chest,  62 
of  peripheral  vessels,  87 
of  respiratory  movements,  69 
of  skin  and  mucous  membranes, 

92 

of  thorax,  60,  96 
Intestinal  colic,  420 

contents,  examination  of,  404 
obstruction,  acute  and  chronic, 

403 

obstruction,  by  gall-stone,  397 
obstruction,  causes  of,  403,  404 
obstruction,  chronic,  visible  peri- 
stalsis in ,  403 
obstruction,  face  in,  12 
obstruction,  physical  signs  in,  403 
obstruction,  symptoms  in,  403 
parasites,  406 
tenderness,  400 
tenesmus,  400 

Intestines,  cancer  of,  signs  and  symp- 
toms of,  404 

diseases  of,  constitutional  mani- 
festations, 400 
diseases  of,  data  for  diagnosis, 

399 

diseases  of,  statistics  on,  399 
gaseous  distention  in,  and  its  sig- 
nificance, 400 
pain,  400 
parasites  in,  eggs,  diagnosis  of, 

408-409 
Iritis,  with  regular  outline  of  pupil, 

15 
Ischio-rectal  abscess,  443 

JACKSONIAN  epilepsy,  44 

epilepsy,  spasms  of  hand,  causes 

of,  44 
Jaundice,  14,  93,  392 

catarrhal,  393 


Jaundice,  causes  of,  14,  392 

congenital,  394 

diagnosis  of  cause,  393 

in  acute  yellow  atrophy,  394 

in  biliary  cirrhosis,  393 

in  cancerous  obstruction  of  gall- 
duct,  396,  397 

in  cholelithiasis,  393 

in  new-born,  393 

in  portal  cirrhosis,  393 

in  syphilis,  393 

in  toxaemia,  392 

in  urine,  393 

in  Weil's  disease,  394 

itching  in,  14 

malignant,  393 

mental  depression  in,  14 

of  eye,  distinguished  from  sub- 
conjunctival  fat,  14 

of  malaria,  15 

of  mucous  membrane,  14 

of  new-born,  15 

of  pernicious  anaemia,  15 

of  sepsis,  15 

of  skin,  14 

results  of,  on  body,  393 

secondary,  in  septicaemia,  394 

slow  pulse  in,  14 

stools  in,  393 

with  bile  in  urine,  14 

with  bile-stained  sweat,  14 

with  catarrh  of  bile-ducts,  14 

with  hepatic  cirrhosis,  15 

with  obstruction  by  stone,  15 

with  syphilis,  15 

with  toxaemia,  15 

with    tumors    obstructing    bile- 
ducts,  15 

Jaw  in  acromegalia,  10 
Jaw-jerk,  test  for,  516 
Joints,  ankylosis  of,  493 


558 


INDEX. 


Joints,  arthritis  of,  494  % 

arthritis  of,  order  of  frequency 

in,  494 

bony  outgrowths,  490 
capsular   thickening   and   adhe- 
sions of,  motion  in,  492 
chronic  diseases  of,  knee-jerks  in, 

515 

creaking  in,  493 
crepitus  in,  493 
diseases  of,  493 
diseases  of,  general  spasm  in, 

490-491 

diseases  of,  pseas-spasm  in,  490 
diseases  of,  shortening  of  limb  in, 

493 

diseases  of,  symptoms  of,  489 
enlargement  of,  489 
examination  of,  488 
excessive  motion  in,  493 
exudates  in,  490 
fluctuation  in,  489 
free  bodies  in,  493        • 
hip,    hypertrophic    arthritis    of, 

500 

in  atrophic  arthritis,  499 
in  hsemophilic  arthritis,  505 
in  rheumatoid  arthritis,  499 
inspection  of,  488 
irregularities  of  contour,  490 
lesions  of,  relative  frequency  in, 

506 

lesions  of,  statistics  on,  506 
limitations  of  motion,  tests  of, 

491 

muscular  spasm,  tests  for,  491 
palpation  of,  488 
radioscopy,  489 
sacro-iliac,  hypertrophic  arthritis 

of,  53 
sacro-iliac,  tuberculosis  of,  53 


Joints,  spindle,  in  atrophic  arthritis, 

47 
symmetrical  involvement  of,  in 

arthritis,  499 
to   distinguish   muscular    spasm 

from  bony  outgrowth,  492 

KERATITIS,  syphilitic,  16 
Kernig's  sign,  test  for,  515 
Kidney,  416 

abscess  of,  418 

abscess  of,  etiology,  419 

abscess  of,  signs  of,  419 

contracted,  urine  in,  438 

cyst  of,  417,  418 

cyst  of,  distinguished  from   hy- 
*      dronephrosis,  418 

diseases  of,  417 

diseases  of,  evidence  of,  416 

diseases  of,  pain  in,  420 

diseases  of,  urine  in,  420,  425, 
428 

floating,  419 

floating,  pain  in,  395 

floating,  tenderness  in,  417 

malignant  disease  of,  417 

movable,  419 

palpation  of,  368,  417 

statistics  on,  416 

tumors,  characteristics  of,  417 

tumors  of,  417 

tumors  of,  method  of  examina- 
tion, 417 

tumors  of,  urine  in,  425 
Knee,  460 

housemaid's,  diagnosis  of,  460 

tuberculosis     of,     distinguished 

from  sarcoma,  457 
Knee-jerk,  absence  of,  513 
Knee-jerks,  increased,  differential  di- 
agnosis in,  514 


INDEX. 


559 


Knee-jerks,  in  paralysis,  520 

test  for,  513 
Knock-knee,  460 
Koplik's  spots  in  measles,  25 
Kyphosis,  54 

in  emphysema,  54 

in  hypertrophic  arthritis,  54 

in  Paget's  disease,  54 

in  Pott's  disease,  54 

in  rickets,  54 

L AMELIA  intestinalis,  407 

Lavage,  of  stomach,  method,  379 

Lead-colic,  pain  in,  396 

Lead-line,  24 

Lead-poisoning,  paralysis  in,  36,  37 
respiratory  movements  of  belly 
in,  366 

Legs,  bowed,  460 

chronic  ulcers  of,  460 
in  cretinism,  10 
in  hysteria,  459 
in  multiple  sclerosis,  459 
in  spastic  paraplegia,  459 
in  tabes  dorsalis,  459 
oadema  of,  causes  of,  461 
osteomyelitis  in,  461 
paralysis  of,  causes,  458 
paralysis  of,  differential  diagno- 
sis in,  459 
sarcoma  of,  461 
tenderness  of,  in  neuritis,  461 
tenderness  of,  in  trichiniasis,  461 
varicose  veins  of,  460 

Leprosy,  11 
face  in,  11 
hand  in,  50 
skin  in,  11 

Leucocyte-count  in  general  peritoni- 
tis, 374 

Leucocytosis,  diagnostic  value  of,  480 


Leucocytosis,  in  appendicitis,  402 

in  local  peritonitis,  373 

in  osteomyelitis,  acute,  456 

occurrence  of,  480 
Leukaemia,  inguinal  glands  in,  455 

liver  in,  391 

lymphatic,  blood  in,  481-483 

myelogenous,  blood  in,  481-482 

myelogenous,  x-ray  in,  482 

nosebleed  in,  17 

spleen  in,  414-415 

tonsils  in,  28 
Leukoplakia  buccalis,  23 
Lineae  albicantes,  363 
Lipoma  of  arm,  38 
Lipomata  of  back,  55 
Lips,  18 

angioneurotic  redema  of,  19,  20 

cancer  of,  glands  in,  30 

chancre  of,  19 

color  of,  18 

epithelioma  of,  19 

in  cretinism,  18-20 

in  heart  disease,  18 

in  lung  diseases,  18 

in  metha3moglobina3mia,  18 

in  myxo3dema,  20 

in  poisoning  by  acetanilid,  18 

in    poisoning   by    coal-tar   anti- 
pyretics, 18 
Litmus- test,  426 
Litten's  sign,  76,  78,  306 
Liver,  abscess  of,  distinguished  from 
syphilis  or  malignant  disease, 
390 

abscess  of,  symptoms  in,  390 

acute  yellow  atrophy  of,  391 

amyloid,  disease  of,  390 

atrophy  of,  391 

cancer  of,  389 

cancer  of,  diagnosis  of,  390 


560 


INDEX. 


Liver,  cancer  of,  emaciation  in,  390 
cirrhosis  of,  389 
cirrhosis  of,  abdominal  veins  in, 

365 

cirrhosis  of,  anaemia  in,  478 
cirrhosis  of,  atrophic,  391 
cirrhosis  of,  emaciation  in,  2 
cirrhosis  of,  latent,  389 
cirrhosis  of,  portal  obstruction  in, 

389 

cirrhosis  of,  uncompensated,  389 
congestion  of,  389 
diseases  of,  387 
diseases  of,   cerebral  symptoms 

in,  395 

diseases  of,  signs  in,  387 
enlargement,  388 
enlargement,  causes  of,  389 
enlargement,     conditions     with 

which  confounded,  388 
enlargement,  diagnosis  of,  388 
enlargement,  in  obstructive  jaun- 
dice, 390 
fatty,  389 

growth  of,  in  cancer,  390 
hydatid  disease  of,  391 
in  leukaemia,  391 
malignant  disease  of,  symptoms 

in,  394 

pain  and  tenderness  in,  387 
palpable  normally,  368 
portal  obstruction  in,  391 
statistics  on,  386 
syphilis  of,  390 
syphilis  of,   distinguished    from 

cirrhosis  or  malignant  disease, 

390 

tumors  of,  377 
Locomotor  ataxia,  atrophic  arthritis 

in,  499 
Lordosis,  54 


Lordosis  in  muscular  dystrophy,  54 

in  tuberculosis,  54 

with  abdominal  tumors,  54 

with  pregnancy,  54 
Lumbago,  53 
Lung,  abscess  of,  21 ,  359 

•    acute  miliary  tuberculosis  of,  316 

adventitious  sounds  (see  R&les) 

anatomy  of,  57 

atelectasis  of,  82,  163,  304-,  361 

auscultation  of,  149-165 

cancer  of,  67,  360 

chronic    interstitial   pneumonia, 
83,  315,  324 

cirrhosis  of,  324 

collapse  of  (see  Ateleitasis) 

congestion  of  (see  (Edema) 

consolidation  of  (see  Solidifica- 
tion) 

diseases  of,  292-329 

diseases  of,  fingers  in,  47,  49 

diseases  of,  lips  in,  18 

emphysema  of,  317-321 

fibroid  disease  of,  83,  315,  324 

fistula  sound,  170 

gangrene  of,  21,  359 

hypertrophy  of,  67,  321 

malignant  disease  of,  67,  360 

miliary  tuberculosis  of,  316 

oedema  of,  362 

palpation  of,  98 

percussion  of,  131-136 

phthisis,  304-316 

pneumonia,  296,  302,  303,  362 

position  of,  58 

radioscopy  of,  534 

rales  in  disease  of,  161,  306 

reflex,  136 

Rontgen  ray  examination  of,  57, 
359 

sarcoma  of,  30,  38,  360 


INDEX. 


561 


Lung,  solidification  of,  298,  311,  323 
sputa  in  diseases  of,  324 
syphilis  of,  323 
tuberculosis  of,  304-316 
Lupus  erythematosus,  nose  in,  17 
Lymphangiectasis,  filarial,  455  " 
Lymphatic  leukaemia,  blood  in,  481 

glands  in,  30 
Lymphocyte  cells,  in  blood,  473 

cells,  in  pleural  fluid,  355 
Lymphocytosis,  481 
in  debility,  481 

MALARIA,  anaemia  in,  478 

chills  in,  3 

jaundice  of,  394 

parasites  in,  484 

spleen  in,  414 

with  jaundice,  15 
Malignant  disease,  anaemia  in,  478 
Malnutrition,  2 

emaciation  in,  2 

in  anorexia  nervosa,  2 

in  chronic  diarrhoea,  2 

in  chronic  dyspepsia,  2 

in  diabetes,  2 

in  gastric  cancer,  2 

in  gastric  dilatation,  2 

in  gastric  ulcer,  2 

in  infantile  atrophies,  2 

in  oasophageal  stricture,  2 
Massage,  leucocytosis  in,  480 
Mast  cells,  in  blood,  473 
Measles,  conjunctivitis  in,  14 

Koplik's  spots  in,  25 

oadema  of  face  in,  10,  14 
Mediastinal   glands,   tuberculosis  of, 
526 

pressure,  signs,  284,  523 

tumors,  38,  290 
Mediastinitis,  276,  278,  526 
36 


Mediastinum,  diseases  of,  523-527 
Megaloblasts,  472,  477,  479 
Melaena,  385 

Meningitis,  bulging  fontanels  in,  6 
strabismus  in,  16 

.  tuberculous,  optic  neuritis  in,  16 
Mensuration,  56 

Mental  symptoms  in  myxoedema,  10 
Meralgia  parsesthetica,  457 
Mesenteric  thrombosis,  375 
Mesentery,  enlarged  glands  of,  373 
Metallic  tinkle,  170,  232 
Metatarsalgia,  465 
Meteorism,  respiratory  movements  of 

belly  in,  366 
Methaemoglobinaemia,  lips  in,  18 

test  of,  18 
Microcephalia,  5 
Migraine,  aphasia  in,  518 
Mind,  depression  of,  in  jaundice,  393 

in  general  peritonitis,  373 
Mitral    disease,    210,    229    (see    also 
Heart) 

regurgitation,  210 

stenosis,  220 
Monoplegia,  508 

leg  in,  459 

Morbus  coxae  senilis,  500 
Morton's  disease,  465 
Morvan's  disease,  50 
Motion,  disorders  of,  507 
Mouth,  canker-sores  of,  19 

fissures  in,  18 

herpes  of,  18,  19 

in  adenoids,  10-18 

in  cretinism,  18-20 

in  dyspnoea,  18 

in  idiocy,  18 

mucous  patches  in,  18-25 

syphilitic  ulcers  of,  18 
Movements,  respiratory,  69 


562 


INDEX. 


Mucous  membrane  in  jaundice,  14 

Mucus  in  feces,  405 

Multiple  sclerosis,    intestinal    tremor 

of,  44 

sclerosis,  knee-jerks  in,  515 
sclerosis,  nystagmus  in,  16,  44 
sclerosis,  paraplegia  in,  459 
sclerosis,  speech  in,  44 
sclerosis,  tremor  in,  44 
sclerosis,  with  spastic  gait,  44 

Mumps,  30 

"accidental,"  194 
orchitis  in,  446 

Murmurs,  arterial,  198 
at  apex,  212 
at  xiphoid,  188 
cardiac,  184-198 
cardio-respiratory,  197 
conduction  of,  188 
diagnostic  interpretation  of,  190, 

249 

diastolic,  187,  234-236 
diastolic,  in  anaemia,  196 
diastolic,  in  aneurism,  286 
diastolic,  in  aortic  area,  286 
diastolic,  in  aortic  regurgitation, 

234 
diastolic,  in  ensiform  cartilage, 

234 

diastolic,  in  mitral  area,  235 
diastolic,  in  mitral  stenosis,  224 
diastolic,  in  pulmonary  area,  251 
diastolic,  in  pulmonary  regurgi- 
tation, 251 

disappearance  of,  191,  225 
effects  of  exercise  on,  193 
effects  of  position  on,  193 
effects  of  respiration  on,  193 
from  pressure,  198 
functional,  194,  195,  196,  244 
haemic  (see  Functional) 


Murmurs  in  aortic  aneurism,  285 

in  aortic  area,  235,  239,  240-246 

in  aortic  regurgitation,  235 

in  aortic   roughening,    219,   238, 

244 

in  aortic  stenosis,  240 
in  back,  212 
in  mitral  area,    212,    218,  222. 

226 

in  mitral  regurgitation,  212,  218 
in  mitral  stenosis,  222-225 
in  neck,  196,  198 
in  pulmonary  area,  196,  251 ,  252 
in  pulmonary  regurgitation,  251 
in  pulmonary  stenosis,  252 
in  relative  insufficiency,  239,  244 
in  tricuspid  area,  188,  247 
in  tricuspid  regurgitation,  247 
in  tricuspid  stenosis,  247 
length  of,  193 
maximum  intensity  of,  190 
metamorphosis  of,  194 
musical,  192 
of  anaemia,  196,  244 
of  Flint,  227,  239 
organic,  190,  196 
position  of,  187 
presystolic,  187 
production  of,  184 
quality  of,  192 
significance  of,  190 
systolic,  at  apex,  212 
systolic,  at  base,  240 
systolic,  in  tricuspid  area,  188, 

247 

systolic,  over  arteries,  198 
terminology  of,  184 
time  of,  186 
transmission  of,  188 
vascular,  198 
venous,  198 


INDEX. 


563 


Muscle,  ilio-psoas,  when  palpable,  368 

sounds,  146,  295 

Muscular  dystrophy,  lordosis  in,  54 
Mydriasis,  causes  of,  15 
Myelitis,  acute,  bedsores  in,  519 

sexual  power  in,  517 

transverse  or  diffuse,  paraplegia 

in,  459 
Myocarditis,  acute,  257 

chronic  interstitial,  258 

diagnosis  of,  259 

hot  feet  in,  464 

in  acute  rheumatism,  257 

physical  signs  in,  258 
Myoma  of  uterus,  450 
Myxosdema,  10 

changes  of  nails  in,  52 

diagnosis  by  palpation,  10 

dry  skin  in,  10 

face  in,  10 

hand  in,  46-48 

increase  of  weight  in,  1 

infantile  form,  10 

infiltration  with  mucin  in,  1 

lips  in,  20 

loss  of  hair  in,  8,  10 

mental  d ulness  in,  10 

nose  in,  17 

onset  of  symptoms  in,  10 

puffiness  of  face  in,  10 

subnormal  temperature  in,  10 

temperature  in,  3 

tongue  in,  24 

NAILS,  52 

capillary  pulse,  52 
changes,  in  chronic  skin 

52 

changes,  in  hemiplegia,  52 
changes,  in  myxoedema,  52 
changes,  in  neuritis,  52 


Nails,  changes,  in  pulmonary  osteoar- 
thropathy,  47-49 

changes,  in  syringomyelia,  52 

disturbed  nutrition  of,  52 

grooved,  after  acute  disease,  52 

in  anaemia,  52 

in  cyanosis,  52 

incurvation  of,  47,  49,  52 

indolent  sores  around,  52 
Navel,  inflammation  or  thickening  of, 

369 
Neck,  29 

abscess  of,  29-31 

actinomycosis  of,  34 

diseases  of,  29-35 

in  emphysema,  29 

in  paralysis  agitans,  11 

in  phthisis,  29 

length  of,  64 

pulsations  in,  33,  34 

scars  of,  29-31 
Necrosis,  anaesthetic,  in  leprosy,  50 

of  bone,  in  tuberculous  arthritis, 

494 
Nephritis,  acute,  urine  in,  437 

chronic  diffuse,  face  in,  12 

chronic  glomerulo-,  anaemia  in, 
478 

diagnosis  of,  r4 

face  in,  12 

glomerular,    chronic,    urine    in, 
437 

glomerular,  polyuria  in,  438 

oedema  of  arm  in,  38 

oedema  of  eyelids  in,  14 

optic  neuritis  in,  16 

parenchymatous,  437 

retinal  hemorrhage  in,  16 

symptoms,  425 

temperature  in,  3 

urine  in,  425 


564  INDEX. 

Nephrolithiasis,  symptoms  in,  425  Nose,  in  acne  rosacea,  17 

urine  in,  425  *    in  acromegalia,  10,  17 

Nervousness,  tremor  of  hands  in,  43  in  adenoids,  17 

Nervous  system,  507  in  alcoholism,  12,  17 

Neuralgia,  75  in  dyspnoea,  17 

red,  of  extremities,  464  in  lupus  erythematosus,  17 

Neurasthenia,  fibrillary  twitchings  in,  in  myxoedema,  17 

510  local  diseases  of,  17 

knee-jerk  in,  513  significance  of  dried  blood  in,  17 

with  ptosis,  16  size  and  shape,  17 

Neuritis,  anaesthesia  in,  36  tuberculosis  of,  17 

atrophy  of  arm  in,  37  Nosebleed,  17 

changes  of  nail  in,  52  in  fever,  17 

due  to  pressure,  35  in  haemophilia,  17 

hysterical,  paralysis  in,  36  in  leukaemia,  17 

multiple,  paralysis  in,  37  in  purpura,  17 

obstetrical,  paralysis  in,  36  in  trauma,  17 

optic,  16  Nutrition  of  chest,  65 

pain  in,  36  Nystagmus,  16-44 

paraesthesia  in,  36  multiple  sclerosis  with,  16 
paralysis  of  leg  in,  458 

postdiphtheritic,  29  OBESITY,  1 

pressure,  paralysis  in,  35  Obstruction,  laryngeal,  76 

pressure,  test  for,  36  Ocular  motions,  16 

tenderness  of  leg  in,  461  (Edema,  93,  217 

toxic,  paralysis,  in,  36  angioneurotic,  461 

with   partial   paralysis   of   both  diagnosis  of  cause,  38 

legs,  459  in  anaemia,  461 

New-born,  jaundice  in,  393  in  deficient  local  circulation,  461 

Nodes,  bony,  in  syphilis,  on  leg,  461  in  flat-foot,  461 

Heberden*s,  47-50  in  hemiplegia,  461 

in  hypertrophic  arthritis,  500  in  inflammation,  461 

on  forehead,  9  in  nephritis,  461 

syphilitic,  9-38  in  neuritis,,  461 

Noma,  26  in  obesity,  461 

Normoblasts  in  blood,  472,  477,  479     .  in  pressure,  461 

Nose,  17  in  thrombosis,  461 

epithelioma  of,  17  in  uncompensated  heart  lesions, 

falling  of  bridge  in,  17  461 

hemorrhage    of    mucous    mem-  in  varicose  veins,  461 

brane  in,  17  of  arm  in  mediastinal  disease.  523 


INDEX. 


565 


(Edema  of  eyelids,  13,  14 

of  lungs,  294,  362 
(Esophagus,  stricture  of,  2 
Oliguria,  421 

Omentum,  tubercular  deposits  in,  377 
Opium-poisoning,  coma  in,  521 

shaking  of  head  in,  13 
Optic  atrophy,  16 

atrophy,  as  result  of  optic  neuri- 
tis, 16 

neuritis,  16 
Orchitis,  446 
Osteitis  deformans,  6,  458 

deformans,  bony  thickening  in,  6 
Osteoarthritis,  501 
Osteo-arthropathy,    pulmonary,    hy- 

pertrophic,  40-43,  47 
Osteorna  of  thigh,  456 
Osteomyelitis,  acute,  leucocytosis  in, 
456 

acute  septic,  455 

acute  septic,  diagnosis  from  ar- 
thritis, 456 

chronic  tuberculous,  456 

tibia  in,  461 

Ovarian  disease,  diagnosis  of,  452,  453 
Ovaries,  451 

abscess  of,  451 

cyst  of,  451-452 

cyst  of,  with  twisted  pedicle,  452 

tumors  of,  452 
Ovaritis,  451 
Oxaluria,  435 
Oxyuris  vermicularis,  407 

FACET'S  disease,  6,  458 
disease,  arm  in,  40 
disease,  bony  thickening  in,  6 
disease,  enlargement  of  skull  in,  6 
disease,  with  kyphosis,  54 

Pain,  in  cancer  of  stomach,  384 


Pain,  in  intestinal  diseases,  400 

in  kidney  disease,  420 

in  liver  disease,  387 

in  local  peritonitis,  373 

in  lumbago,  53 

in  obstetrical  neuritis,  36 

in  osteomyelitis,  461 

in  pressure  neuritis,  35 

in  syphilitic  nodes  of  humerus,  38 

in  toxic  neuritis,  36 
Palate,  paralysis  of,  absence  or  di- 
minished reflex  in,  29 

soft,  adhesions,  29 

soft,  perforation  of,  29 
Pallor,  93 

in  phthisis,  12 
Palpation,  96-103 

and  dipping,  371 

and  friction,  pleural  or  pericar- 
dial,  100 

in  aneurism,  280-282 

in  myxoedema,  10 

of  abdomen ,  methods  of,  366 

of  apex-beat,  96 

of  normal  abdomen,  368 

of  rales,  101 

of  the  pulse,  103-111 

of  thrills,  97 

of  voice  vibrations,  98 

(see  also  Fremitus) 
Palpitation,  264 
Pancreas,  397 

cancer  of,  diagnosis  of,  397 

cancer  of,  jaundice  of,  396,  397 

cyst  of,  398 

diseases  of,  397 

diseases  of,  aids  in  diagnosis  of, 
398 

diseases  of,  diabetes  in,  398 

diseases  of,  diagnosis  of,  397 

diseases  of,  stools  in,  397 


566 


INDEX. 


Pancreas,  diseases  of,  urine  in,  397 

statistics  on,  398 

tumor  of,  375-397 

tumor  of,  gall-bladder  in,  397 
Pancreatitis,  acute,  398 
Paraesthesia,  512 

in  neuritis,  36 

Paralyses,  cerebral,  knee-jerk  in,  514 
Paralysis,  508 

agitans,  11-13 

agitans,  face  in,  11 

agitans,  gait  in,  508 

agitans,  hands  in,  13 

agitans,  rigidity  of  neck  in,  11 

agitans,  tremor  of  hands  in,  44 

bulbar,  29 

congenital,     choreiform     move- 
ments in,  45 

in  acute  anterior  poliomyelitis, 
36 

in  anterior  poliomyelitis,  458 

in  chorea,  459 

in  diseases  of  spinal  cord,  37 

in  hemiplegia,  458 

in  hysteria,  36,  458,  459,  508 

in  lead-poisoning,  36,  37 

in  multiple  neuritis,  37 

in  multiple  sclerosis,  459 

in  neuritis,  458 

in  obstetrical  neuritis,  36 

in  pressure  neuritis,  36 

in  tabes,  459 

in  toxic  neuritis,  36,  37 

in  transverse  myelitis,  459 

in  traumatic  neurosis,  36 

infantile  cerebral,  athetosis  in,  45 

of  brain,  508 

of  cord,  508 

of  cranial  nerve,  508 

of    interossei    and    lumbricales, 
claw-hand  in,  46 


Paralysis    of    intestines,    in    general 
peritonitis,  373 

of  leg,  458 

of  median  or  ulnar  nerves,  claw- 
hand  in,  46 

of  palate,  test  for,  29 

of  peripheral  nerve,  508 

serratus,  scapula  in,  55 

with  contraction  of  pupil,  15 
Paralytic  thorax,  63 
Paraphimosis,  445 
Paraplegia,  457,  508 

spastic,  459 

Parasites,   animal,   diseases  due   to, 
blood  in,  481 

in  feces,  406 

in  the  blood,  484 

intestinal,  anaemia  in,  478 

intestinal,  eggs  of,  408-409 
Paresis,  508 
Paronychia,  52 
Parotid  gland,  cancer  of,  30 

gland,  enlargement  of,  30 
Parturition,  leucocytosis  in,  480 
Passive  congestion,  in  liver  enlarge- 
ment, 389 

Patella,  floating  of,  test  for,  490 
Pectus  carinatum,  62 
Pediculi  in  hair,  8 
Penis,  445 

cancer  of,  446 

chancre  of,  445 

chancroid  of,  445 

discharge  from,  445 

inflammation  of  glands  of,  445 

malformations  of,  435 
Peptic  ulcer,  pain  in,  395 
Percussion,  auscultatory,  125 

force  of,  122 

immediate,  118 

mediate,  119-136 


INDEX. 


567 


Percussion  of  abdomen,  371 

of  lung  borders,  133 

outlines  of  thoracic  organs,  58, 
128 

palpatory,  136 

resonance,  127 

resonance,  amphoric,  135 

resonance,  cracked-pot,  134 

resonance,  dull,  128 

resonance,  flat,  128 

resonance,  tympanitic,  130 

resonance,  vesicular,  128 

technique  of,  118 

Pericardia!  friction  (see  Pericarditis') 
Pericarditis,  acute  plastic,  268 

diagnosis  of,  270,  275 

dry,  268 

fibrinous,  268 

friction,  diagnosis  of,  270 

friction  in,  268 

with  effusion,  271 

with  effusion,  diagnosis  of,  275 
Pericardium,  adherent,  276 

diseases  of,  268-280 
Perinephritic  abscess,  54,  418 

abscess,  psoas  spasm  in,  495 
Perineum,  ruptured,  448 
Periostitis,  461 

Peripheral  nerve  lesions,  anesthesia 
in,  512 

nerve  lesions,  hypersesthesia  in, 
512 

nerve  paralysis,  508 

neuritis,  knee-jerk  in,  514,  515 
Peristalsis,  visible,  gastric,  377 

visible,  in  intestinal  obstruction, 

403 

Peritoneum,   cancer  of,   anaemia   in, 
374 

cancer  of,  ascites  in,  374 

cancer  of,  emaciation  in,  374 


Peritoneum,     cancer    of,     signs     in, 

374 

cancer  of,  tumors  in,  374 
diseases  of,  372 

tuberculosis  of,  anaemia  in,  374 
tuberculosis  of,  ascites  in,  374 
tuberculosis   of,   emaciation    in, 

374 
tuberculosis  of,  signs  in,  374 

Peritonitis,  372 
causes  of,  373 
general,  373 

general,  facial  expression  in,  374 
general,  fever  in,  373 
general,   intestinal  paralysis  in, 

373 

general,  leucocyte  count  in,  374 
general,  mind  in,  373 
general,  pulse  in,  373 
general,  swollen  belly  in,  373 
general,  tenderness  in,  373 
general,  vomiting  in,  373 
local,  albuminuria  in,  373 
local,  anorexia  in,  373 
local,  constipation  in,  373 
local,  fever  in,  373 
local,  leucocytosis  in,  373 
local,  muscular  spasm  in,  373 
local,  pain  in,  373 
local,  symptoms  in,  373 
local,  tenderness  in,  373 
local,  tumor  in,  373 
respiratory  movements  of  belly 

in,  366 

with  thickening  or  inflammation 
of  navel,  369 

Peri-urethral  abscess,  445 

Pernicious  ansemia,  blood  in,  478 
anemia,  jaundice  of,  394 
anaemia,  remissions  in,  479 
ansemia,  with  jaundice,  15 


568  INDEX. 

Pharyngitis,  general  redness  in,  26  Pleural  effusion,  diagnosis  frompneu- 

of  smokers,  29  monia,  362 

Pharynx,  26  effusion,    diagnosis    from    sub- 
abscess  of,  28  diaphragmatic  effusions,  354 
in  diphtheria,  26  effusion,  encapsulated,  350 
in  pharyngitis,  26  effusion,  signs  during  absorption 
in  scarlet  fever,  26  of,  350 
method  of  examination,  26  exudate,  cells  in,  356 
Phimosis,  445  friction,  100,  165,  337 
Phlebitis,  457  friction,  distinction  from  muscle 
Photophobia,  15                    _,  sounds,  338 
Phthisis,  11,  304-316  friction,  distinction  from  pericar- 
acute,  316  dial  friction,  270 
advanced,  311  friction,   distinction   from   rales, 
chronic,  308-316  338 

dilatation  of  pupils  in,  15  friction,  means  of  eliciting,  166, 

eyelashes  in,  12  167 

eyes  in,  12  thickening,  350.  353 

fibroid,  66  Pleurisy,  330-350 

flush  in,  12  clubbed  fingers  with,  47,  49 

hair  in,  12  diaphragmatic,  337 

incipient,  304  dry,  336 

neck  in,  29  egophony  in,  169 

pallor  in,  12  heart  in,  343,  344 

pupils  in,  12  pain  in,  336 

skin  in,  11  plastic,  336 

thoracic  deformity  in,  64  pulsating,  87,  352 

with  fatty  liver,  389  radioscopy  of,  535 

(see  also  Tuberculosis)  restrained  breathing  in,  75 

Pigmentations  in  buccal  cavity,  26  tuberculous,  356,  357 

"Pink-eye,"  14  Plumbism,  blood  in,  472 

Pin-worm,  in  faeces,  407  gums  in,  24 

Platelets  in  blood,  474  paralysis  in,  36,  37,  458 

Pleura,  cancer  of,  355-360  Pneumococcus  infection,  arthritis  in, 

diseases  of,  330-358  495 

Pleural  adhesions,  78  Pneumonia,  296-304 

cancer     or    hydatid    of     lung,  aspiration,  302 

355  broncho-,  303 

effusion,  70,  76,  338-350  catarrhal,  303 

effusion,  diagnosis  from  pleural  central,  296,  531 

thickening,  353  chronic  interstitial,  324 


INDEX. 


569 


Pneumonia,  crepitant  rales  in,  299 

croupous  (or  lobar),  296 

croupous,  blood  in,  480 

croupous,  diagnosis  from  pleur- 
isy, 302 

croupous,  diagnosis  of,  301 

croupous,  egophony  in,  299 

croupous,  signs  in,  296 

croupous,  sputa  in,  326,  328 

hypostatic,  362 

inhalation,  302 

lobular,  303 

massive,  296 

migratory,  300 

resolution  of,  300 

tuberculous,  302,  304 
Pneumopyothorax,  332 
Pneumoserothorax,  332 
Pneumothorax,  67,  70,  330 
Poikilocytosis  in  blood  smears,  472, 

477 
Poisoning  by  gas,  coma  in,  522 

by  illuminating  gas,  breath  in, 
22 

by  mercury,  gums  in,  25 

by  potassic  iodide,  gums  in,  25 

lead,  lead-line  in,  24 

opium,  coma  in,  521 
Poisons,  anaemia  in,  478 

glucosuria  in,  429 
Poliomyelitis,  anterior,  458 

atrophy  in,  37 

chronic,  claw-hand  in,  46 
Polychromasia  in  blood  smears,  472, 

477 

Polynuclear  cells  in  blood,  473 
Polyuria,  421 
Portal  obstruction,  causes  of,  392 

obstruction,  signs  of,  391 

stasis,  ascites  in,  374 
Postepileptic  coma,  522 


Pott's  disease,  66 

disease,   cervical,  symptoms  of, 

33 

disease,  cervical,  with  abscess,  31 
disease,  diagnosis  of,  495 
disease,  vertebra?  in,  33 
disease,  with  kyphosis,  54 
Pregnancy,  choreiform  movements  in, 

45 

glucosuria  in,  429 
lordosis  in,  54 
spasm  in,  13 
tubal,  451 
Pressure,  arterial,  111-117 

arterial,  methods  of  measuring, 

111 

diastolic,  108,  116 
mediastinal,  523 
systolic,  106,  114 
Presystolic  murmur  (see  Murmur) 
Primary    polyarticular   atrophic   ar- 
thritis, diagnosis  of,  499 
Procidentia,  449 
Progressive  muscular  atrophy,  fibril- 

lary  twitchings  in,  510 
muscular  atrophy,  reaction  of  de- 
generation in,  518 
Prominence,  local,  68 

of  chest,  68 
Prostate,  hypertrophy  of,  distended 

bladder  in,  440-441 
Prostatitis,  acute,  retention  of  urine 

in,  441 

Pseud  o-leuka;mia,  tonsils  in,  28 
Psoas  abscess,  455-457 

spasm  in  disease,  495 
Psychic  functions,  examinations  of, 

519 
Ptosis,  16 

in  hysteria,  16 

in  neurasthenia,  16 


570 


INDEX. 


Ptosis  in  syphilis,  16 
Pulmonary     disease,     292-329     (see 
Lung) 

hemorrhage,  305 

oadema,  294,  362 

osteoarthropathy,  41-43,  47 

regurgitation,  251 

stenosis,  252 

syphilis,  323 

tympanites,  321 
Pulmonicarea,  171, 178, 196, 251, 252 

second  sound,  178 
Pulsating  pleurisy,  87 
Pulsation,-  abnormal,  82-87,  280 

capillary,  91,  232 

epigastric,  85 

venous,  88,  247 

venous,  in  tricuspid  disease,  247 

visible,  85 
Pulse,  103-117 

anacrotic,  107 

bounding,  107 

capillary,  52,  232 

compressibility  of,  106  (see  also 
Arterial  pressure) 

Corrigan's,  233 

dicrotic,  107 

frequency  of,  105,  261 

in  aneurism,  104 

in  aortic  regurgitation,  233 

in  aortic  stenosis,  104,  242 

in  peritonitis,  373 

irregularity  of,  105,  263 

method  of  feeling,  104 

rate,  105 

rhythm  or  regularity,  105 

slow,  262,  393  (see  Bradycardia) 

tension,  108 

value  of,  103 

venous,  88 

volume,  106 


Pulse,  water-hammer,  233 

wave,  size  and  shape  of,  106 

(see  also  Arterial  walls) 

(see  also  Arterial  pressure) 
Pupil,  15 

Argyll-Robertson,  15 

contraction  of,  15 

dilatation  of,  15 

irregularity  of,  15 
Pupils,  in  phthisis,  12 

reflexes,  15,  513 

tests  of  reflexes  of,  15 

with  sluggish  reaction,  15 
Purpura,  nosebleed  in,  17 
Pus  in  faeces,  406 

tube,  450 

tube,  cause  of  peritonitis,  373 
Pylephlebitis,  390 
Pyloric  stenosis,  in  cancer  of  stomach , 

384 

Pylorus,  stenosis  of,  gastric  peristalsis 
in,  377 

stenosis  of,  peristalsis  in,  366 
Pyonephrosis,  418 
Pyorrhoea  alveolaris,  25 
Pyuria,  423,  424 

QUINSY  sore  throat,  28 

RACHITIS,  effects  on  chest,  60-63 

epiphyses  in,  40 

head  in,  6 

teeth  in,  20 

(see  also  Rickets) 
Radioscopy,  79,  287,  529-536 
Rales,  161-165 

bubbling,  161 

consonating,  311 

crackling,  162 

crepitant,  163,  299 

diagnosis  of,  167 


INDEX. 


571 


Rales,  "dry,"  162 

"moist,"  161 

musical,  164 

palpable,  101 

varieties  of,  161 
Raynaud's  disease,  49,  464 

disease,  gangrene  in,  49,  465 

disease,  syncope  in,  49,  519 
Reaction  of  degeneration,  517 
Recti,  separations  of,  369 
Rectum,  abscess  of,  443 

cancer  of,  444 

fissure  of,  443 

fistula  of,  443 

hemorrhoids  of,  443 

methods  of  examination,  443 

symptoms  which  suggest  exami- 
nation, 442 
Reflex,  lung,  136 
Reflexes,  512-513 

deep,  515 

exaggerated  pharyngeal,  29 

in  bulbar  paralysis,  29 

in  postdiphtheritic  neuritis,  29 

of  pupil,  513 

superficial,  516 
Regurgitation,  aortic,  234 

mitral,  212,  218 

pulmonary,  251 

tricuspid,  188,  247 
Penal  calculus,  419 

calculus,  symptoms,  425 

calculus,  urine  in,  425 

colic,  395,  419 

disease,  ascites  in,  374 

disease,  diuresis  in,  1 

disease,  sweating  in,  1 

disease,  weight  in,  1 
Resistance,  sense  of,  136 
Resonance  (see  Percussion  resonance) 
Respiration  (see  Breathing) 


Respiratory  movements,  69-71 

sounds,  151-161  (see  Breathing) 

rhythm,  74 

Restriction  of  thoracic  movements,  70 
Retina,  16 

hemorrhage  of,  16 

hemorrhage  of,  in  anaemia,  16 

hemorrhage  of,  in  diabetes,  16 

hemorrhage  of,  in  nephritis,  16 
Retraction  of  thorax,  70,  73 

causes  of,  76 

causes,  lung,  291,  317 
Retrocele,  448 

Rheumatoid  arthritis,  495,  498 
Rickets,  arm  in,  40 

delayed  closure  of  fontanels  in,  6 

epiphyses  in,  40,  463 

head  in,  6 

rubbing  off  of  hair  of  head  in,  7 

spleen  in,  414 

sweating  of  head  in,  7 

teeth  in,  20 

with  kyphosis,  54 
Romberg's  sign,  511 
Rosary,  rachitic,  63 
Rose  spots,  diagnosis  of,  365 
Round-worm  in  faeces,  407 

SAHLI'S  test  for  haemoglobin,  467 
Salpingitis,  450 
Sarcoma  of  arm,  38,  39 

of  belly  wall,  369 

of  femur,  456-457 

of  leg,  461 

of  lung,  oedema  of  arm  in,  38 

of  mediastinum,  oedema  of  arm 
in,  38 

of  scapula,  55 

of  testis,  446 

of  thyroid  gland,  32 

of  tonsil,  27 


572 


INDEX. 


Scapula,  angel-wing,  55 

prominent,  55 

sarcoma  of,  55 
Scar  from   syphilitic    ulcers   on   leg, 

461 
Scarlet  fever,  pharynx  in,  26 

fever,  tonsils  in,  26,  27,  28 
Scars  of  forehead,  8 

significance  of,  31 
Scoliosis,  with  twisting  of  spine,  54 
Scrotum,  446 

hernia  of,  447 

hydrocele  of,  446 
Scurvy,  gums  in,  25 
Senility,  tremor  of  hands  in,  43 
Sensation,  delayed,  512 

disorders  of,  511 

dissociation,  512 
Sepsis  with  jaundice,  15 
Septicaemia  with  jaundice,  394 
Serratus  paralysis,  scapula  in,  55 
Sexual  power,  517 
Shock,  diastolic,  284 
Sigmoid,  cancer  of,  404 
Skin,  diseases  of,  chronic,  blood  in, 
481 

in  jaundice,  14 

in  leprosy,  11 

in  myxcedema,  10 

in  phthisis,  11 

itching  of,  in  jaundice,  393 

lesions  of,  trophic,  in  atrophic  ar- 
thritis, 499 

Skull,  enlargement  of,  6 
Sleep,  loss  of,  2 
Smallpox,  eruptions  on  forehead  in,  9 

throat  in,  27 
Snuffles,  syphilitic,  17 
Sordes,  25 

Sounds,   cardiac,    171-179   (see  also 
Heart) 


Sounds  in  lung  fistula,  170 

respiratory,    151-161     (see    also 

Breathing) 
Spade-hand,  46 
Spasm,  muscular,  373,  490-492,  494 

psoas,  495 

tonic,  509-510 
Spasms,  clonic,  509-510 

hands  in,  44,  45,  46 

of  face,  13 

Spastic  paraplegia,  knee-jerk  in,  512 
Speech,  loss  of,  518 
Sphincteric  reflexes,  517 
Sphygmograph,  535 
Sphygmometer,  111  (see  Blood  press- 
ure) 

Spina  bifida,  55 

Spinal  cord,  pressure  on,  paraplegia 
in,  459 

cord,  severing  of,  knee-jerk  in, 
514 

curvature,  54,  66,  70 

curvature,  scapula  in,  55 
Spine,  chronic  diseases  of,  sphincteric 
reflexes  in,  517 

in    hypertrophic    arthritis,    501, 
502,  503,  504 

normal  flexibility  of,  504 

tuberculosis  of,  495 
Spleen,  diseases  of,  59,  412 

enlarged,      distinguished      from 
other    tumors,  415 

enlargement  of,  412,  414,  415 

palpation  of,  412-414 

percussion  of,  414 

in  portal  obstruction,  392 
Splenic  anaemia,  414,  415 
Spondylitis  deformans,  501 
Sputa,  appearance  of,  324 

examination  of,  324-329 

odor  of,  325 


INDEX. 


573 


Sputa,  origin  of,  324 

staining  of,  326 
Squint,  16 

Starvation,  breath  in,  21 
Statistics  on  bladder,  439 

on   gall-bladder  and   bile-ducts, 
387 

on  diseases  of  liver,  399 

on  joint  lesions,  506 

on  kidney,  416 

on  liver  disease,  386 

on  pancreatic  disease,  378 

on  thigh  disease,  455 

on  thigh  tumors,  456 
Stenosis,  aortic,  239 

mitral,  220 

of  a  bronchus,  73,  286,  323 

pulmonary,  252 

tricuspid,  250 
Stethoscope,  choice  of,  138 

use  of,  143 

varieties  of,  138 
Stomach,  376 

cancer  of,  384,  385 

cancer  of,  glands  in,  30 

cancer  of,  statistics,  384 

cancer  of,  vomitus  in,  385 

contents,  acetic  acid  in,  382 

contents,  acidity  of,  381 

contents,  blood  in,  381 

contents,  blood  in,  tests  for,  381 

contents,  chemical  tests  of,  382 

contents,  color  of,  381 

contents,  determination  of  total 
acidity  of,  382 

contents,  free  hydrochloric  acid 
in,  tests  for,  382 

contents,     general     appearance, 
381 

contents,  in  achylia  gastrica,  382 

contents,  in  fermentation,  382 


Stomach,  contents,  in  stasis,  310 
contents,  inspection  of,  382 
contents,  lactic  acid  in,  383 
contents,  lactic  acid  in,  test  for, 

383 
contents,   method   of  obtaining, 

381 

contents,  mucus  in,  382 
contents,  nitric  acid  in,  382 
contents,  normal  quantity  of,  381 
contents,  odor  of,  381 
contents,  sediment  in,  384 
contents,  significance  of  organic 

acids  in,  384 

contents,  total  acidity,  383 
dilatation  of,  378 
dilatation  of,  causes  and  symp- 
toms, 385 

dilatation  of,  diagnosis,  386 
dilatation  of,  statistics  of,  384 
diseases  of,  incidence  and  diagno- 
sis of,  384 

distention  of,  methods,  380 
estimation  of  size  and  position, 

378,  380 

fluid  in,  palpation  of,  368 
hyperacidity  in,  385 
hypoacidity  in,  385 
hypogastric  bulging  of,  378 
inspection  and  palpation,  376 
methods  of  examination,  376 
normal  splash  sound  in,  378 
passing  of  tubes,  378 
secreting  and   motor  power  of, 

378 
test  meal  for  examination  of,  379, 

381 

tumor  in  cancer  of,  377 
ulcer  of,  statistics  of,  384 
visible  peristalsis  in,  377 
washing  of,  method,  381 


574  INDEX. 

Stomatitis,  breath  in,  21  Syphilis,  palate  in,  29 
gangrenous,  26  periostitis  in,  461 

Stools  in  gastric  ulcer,  385  periostitis,  scars  on  forehead  re- 

in jaundice,  14,  393  suiting  from,  8 

in  pancreatic  disease,  397  ptosis  in,  16 

Strabismus,  16  sores  about  nails  in,  52 

Stridor,  respiratory,  523  strabismus  in,  16 

Strongyloides  intestinalis,  407,  412  tonsils  in,  27 

Strychnine  poisoning,  spasm  in,  510       Syringomyelia,   changes  of  nails   in, 

Subsultus  tendinum,  43  52 

Succussion,  169,  332  claw-hand  in,  46 

Sugar,  428  (see  Glucosuria)  felons  in,  50 

Sunstroke,  coma  in,  522  Morton's  disease  in,  50 

fever  in,  3  with  atrophic  arthritis,  498 

Suppurations,    chronic,    anaemia    in,      Systolic  murmur  (see  Murmur) 
478 

Sweat,  in  jaundice,  14  TABES  dorsalis,  ataxia  in,  510 

Syncope,  521  dorsalis,  knee-jerk  in,  514 

local,  in  Raynaud's  disease,  49  dorsalis,  optic  neuritis  in,  16 

Syphilis,  arthritis  in,  495  dorsalis,  parsesthesia  in,  512 

breath  in,  21  dorsalis,  paraplegia  in,  459 

chancre  of  penis  in,  445  dorsalis,  reaction  of  pupil  in,  15 

congenital,  teeth  in,  20,  21  dorsalis,  Romberg's  sign  in,  511 

coryza  in,  17  dorsalis,  sexual  power  in,  517 

dactylitis  in,  48-50  dorsalis,  sphincteric  reflexes  in, 

eruptions  on  forehead  in,  9  517 

glands  of  neck  in,  30  ulcer  of  toe  in,  465 

hereditary,    delayed    closure    of  with  atrophic  arthritis,  498 

fontanels  in,  6  with  contraction  of  pupil,  15 

inguinal  glands  in,  454  Tachycardia,  261 

jaundice  in,  393  Tactile  fremitus,  98, 297,  308, 318, 350 

keratitis  in,  16  Tsenia  saginata,  407,  408 
loss  of  hair  in,  7  solium,  407,  409 

mucous  patches  in,  18-25  nana,  407,  410 

nodes  on  humerus  in,  38  Tallqvist's  test  for  haemoglobin,  466 

nose  in,  17  Tape- worm  in  faeces,  407,  411 

of  frontal  bone,  7  Teeth,  20 
of  liver,  390  grinding  of,  21 

of  lung,  325  in  congenital  syphilis,  20 

of  tongue,  23  in  cretinism,  20 

orchitis  in,  446  in  rickets,  20 


INDEX. 


575 


Teeth,  time  of  appearance,  20 
Temperature,  2 

in  myxoedema,  3,  10 

in  nephritis,  3 

in  osteomyelitis,  acute,  456 

in  pathological  conditions,  3 

in  uncompensated  heart  disease, 
3 

malingering  in,  2 

significance  of,  2 

subnormal,  3 
Tenderness  in  general  peritonitis,  373 

in  intestinal  diseases,  400 

i  i  peritonitis,  373 
Tenosynovitis,  41 

of  Achilles  tendon,  463 
Tension  of  pulse,  108 
Testes,  446 

absence  of  one  or  both,  447 

cancer  of,  446 

hsematocele  of,  447 

retained,  455 

sarcoma  of,  446 
Tetany,  spasms  in,  46 
Thigh,  455 

cancer,  metastatic,  457 

cramps  in,  causes  of,  458 

diseases  of,  statistics  on,  455,  456 

intermittent  claudication  of,  458 

meralgia,  paraesthesia  of,  457 

miscellaneous  lesions  of,  457 

osteoma  of,  456 

sarcoma  of,  456 

significance  of  scars  on,  456 

tumors  of,  statistics,  456 
Thoma-Zeiss  blood  counter,  475 
Thoracic  aneurism  (see  Aneurism) 

deformities,  62-68 

disease,  199-363 

disease,  methods  of  diagnosis  in, 
56-198 


Thorax,  paralytic,  63 

tender  points  on,  102 
Thrill,  97 

in  aortic  aneurism,  282 

in  aortic  stenosis,  243 

in  congenital  heart  lesions,  265, 
266 

in  mitral  regurgitation,  217 

in  mitral  stenosis,  222 

in  pulmonary  stenosis,  252 
Throat,  in  chickenpox,  27 

in  diphtheria,  26 

in  smallpox,  27 

in  pharyngitis,  26 

in  scarlet  fever,  26,  27,  28 

methods  of  examination,  26 

with  streptococcus  infection,  27 
Thrombosis,  oedema  of  arm  in,  38 

of  mesentery,  375 

of  vein,  460 
Thrush,  27 
Thyroid  gland,  atrophy  of,  31 

gland,  malignancy  of,  32 
Tissues,  accumulation  of  fluid  in,  1 
Tobacco,  shaking  of  head  in,  13 
Toe-drop  gait,  508 
Toes,  465 

lesions  of,  465 

tender,  after  typhoid  fever,  465 
Tongue,  22 

cancer  of,  23 

cancer  of,  glands  in,  30 

canker  of,  22 

coating  of,  22 

cyanosis  of,  22 

dry  brown,  22 

fissures  of,  23 

geographic,  23 

herpes  of,  22 

hypertrophy  of,  24 

in  alcoholism,  22 


576 


INDEX. 


Tongue,  in  cretinism,  10,  24 

in  dementia  paralytica,  22 

in  facial  paralysis,  22 

in  gastric  fermentation,  22 

in  hyperacidity  or  gastric  ulcer, 
22 

in  myxcedema,  24 

in  typhoidal  states,  22 

in  weakness,  22 

indentation  of,  22 

jaundice  in,  22 

leukoplakia  buccalis,  23 

syphilis  of,  23 

tremor  of,  22 

tuberculosis  of,  23 

ulcers  of,  23 

Tonometer,  Gaertner's,  112 
Tonsil,  abscess  of,  28 
Tonsillitis,  acute,  28 

follicular,  28 

with  enlarged  glands,  30 
Tonsils,  26 

enlargement  of,  28 

general  redness  of,  26 

in  adenoids,  28 

in  diphtheria,  26,  27 

in  leukaemia  or  pseudo-leukaemia, 
28 

in  pharyngitis,  26 

in  scarlet  fever,  26,  27,  28 

malignant  disease  of,  27 

membrane  on,  27 

method  of  examination,  26 

sarcoma  of,  glands  in,  30 

syphilitic  ulcerations  of,  27 

tuberculous  ulcerations  of,  27 

yellowish- white  spots  on,  27 
Topfer's  reagent,  382 
Tophi,  gouty,  diagnosis  of,  505 

in  gout,  test  for,  490 
Tort'wllis,  congenital,  32 


Torticollis  with  spasm,  32 
Toxaemias,  fever  in,  3 

in  hepatic  cirrhosis,  2 

in  tuberculosis,  2 

in  typhoid,  2 

leucocytosis  in,  478 

tremor  of  hands  in,  43 

with  jaundice,  15 
Toxaemias,  emaciation  in,  2 
Tracheal  tug,  283 
Tracheitis,  292 
Transverse   myelitis,   anaesthesia    in, 

512 
Traube's  semilunar  tympanitic  space, 

percussion  of,  371 
Trauma,  nosebleed  in,  17 

scars  on  forehead  resulting  from, 

8 

Traumatic  neuroses,  paralysis  in,  36 
Tremor,  510 
Tremors  of  hand,  43 

of  hands  in  alcoholism,  44 

of  hands  in  cold,  43 

of  hands  in  fever,  43 

of  hands  in  Graves'  disease,  44 

of  hands  in  hysteria,  44 

of  hands  in  multiple  sclerosis,  44 

of  hands  in  nervousness,  43 

of  hands  in  old  age,  43 

of  hands  in  paralysis  agitans,  44 

of  hands  in  toxaemia,  43 

of  tongue,  22 
Trichiniasis,  blood  in,  481 

oedema  of  eyelids  :n,  14 

tenderness  of  leg  in,  461 

symptoms  of,  14 
Trichiuris  trichiura,  407,  411 
Trichomonas  intestinalis,  407 
Tricuspid  disease,  188,  247-251 

regurgitation ,  246 

stenosis,  250 


INDEX. 


577 


Trigeminal  neuralgia,  baldness  in,  7 

Trophic  disorders,  519 
disturbances,  48 

Trypanosomiasis,  blood  in,  481 
parasite  in,  485 

Tuberculosis,  arthritis  in,  494 
dactylitis  in,  48-50 
emaciation  in,  2 
epididymitis  in,  446 
in  ankle  bones,  463 
of  belly  wall,  369  - 
of  bone  of  arm,  38-40 
of  cervical  glands,  30 
of  hip,  lordosis  in,  54 
of  knee,  distinguished  from  sar- 
coma, 457 

of  mediastinal  glands,  526 
of  nose,  17 
of  omen  turn,  377 
of  peritoneum,  372,  374 
of  peritoneum,  anaemia  in,  374 
of  peritoneum,  emaciation  in,  374 
of  peritoneum,  signs  in,  374 
of  sacro-iliac  joint,  53 
of  spine,  495 
of  spine,  lordosis  in,  54 
of  the  lungs,  304-316,  534 
of  the  lungs,  acute,  316 
of  the  lungs,  advanced,  311 
of  the  lungs,  cavity  formation  in, 

313 

of  the  lungs,  chronic,  308-316 
of  the  lungs,  cough  in,  305,  306 
of  the  lungs,  diagnosis  of,  304- 

316 

of  the  lungs,  emaciation  in,  310 
of  the  lungs,  fever  in,  304 
of  the  lungs,  hemorrhage  in,  305 
of  the  lungs,  hoarseness  in,  305 
of    the   lungs,  Litten's  signs  in, 
307 

37 


Tuberculosis  of  the   lungs,    physical 

signs  in,  304,  316 
of  the  lungs,  rales  in,  306 
of  the  lungs,  tuberculin  in,  304 
of  the  lungs,   with  emphysema, 

315 

of  tongue,  23 
of  wrist  joint,  40 
orchitis  in,  446 
sores  about  nails  in,  52 
spinal  paraplegia  in,  459 
tonsils  in,  27 
vertebral,  abscess  in,  55 

Tuberculous    peritonitis,    ascites    in, 
374 

Tug,  tracheal,  283 

Tumors,  38 

abdominal,  78,  370 
abdominal,  lordosis  in,  54 
abdominal,     respiratory     move- 
ments of  belly  in,  365 
aneurismal,  281 
congenital,  of  back,  55> 
in  cancer  of  peritoneum,  374 
,  in  cancer  of  stomach,  377 
in  epigastrium,  377,  384 
in  local  peritonitis,  373,  374 
mediastinal,  290 
oedema  of  arm  in,  38 
of  back,  54 
of  liver,  377 
of  pancreas,  377 
of  spine,  66 

Tympanites,  pulmonary,  321 

Typhoid  fever,  breath  in,  21 
fever,  nosebleed  in,  17 
fever,  rose  spots  in.  365 
fever,  spleen  in,  414,  415 
fever,  tender  toes  after,  465 
fever,  toxsemia  in,  2 
fever,  Widal  reaction  in,  483 


578 


INDEX. 


ULCER  in  tuberculous  dactylitis,  49 

of  leg,  460 

of  stomach,  statistics  of,  384 

of  tongue,  23 

perforating,  of  toe,  465 
Uncinaria  americana,  407,  409 

eggs  of,  410 

Uncinariasis,  blood  in,  481 
Uraemia,  aphasia  in,  518 

breath  in,  21 

distinguished  from  apoplexy,  520 
Urate  of  sodium  in  gouty  deposits, 

503 
Urethra,  abscess  of,  445 

caruncle  of,  449 

discharge  from,  445 

glands,  abscess  of,  449 

stricture   of,    distended   bladder 

in,  440 
Urine,  acetone  in,  430 

acute  retention  of,  440 

albumin  in,  427,  428 

albumin  in,  Esbach's  test,  426 

albumin  in,  significance  of,  427, 
428 

albumin  in,  tests  for,  426 

amount,  419 

animal   parasites    in,    435,   436, 
437 

bile  in,  393 

blood  in,  424,  433 

casts  in,  431-433 

chemical  examination  of,  425 

color  of,  422 

crystals  in  sediment,  435 

diacetic  acid  in,  430 

diazo  reaction,  430 

eggs   of   Bilharzia   hsematobium 
in,  412 

glucose  in,  428 

glucose,  Fehling's  test  for,  428 


Urine,     glucose,     fermentation     test 
for,  429 

in  bladder  disease,  441 

in  cystitis,  423 

in  diseases  of  pancreas,  397 

in  jaundice,  14 

in  kidney  disease,  420,  425,  428 

in  renal  suppuration,  423 

optical  properties  of,  422 

overconcentration  of,  441 

pus  in,  423,  434 

pus  in,  diagnosis  of  origin,  423, 
424 

reaction  of,  425 

retention  of,  in  acute  prostatitls, 
441 

sediment  of,  421 

sediment  of  free  cells  in,  433 

sediment  of,  microscopic  exami- 
nation of,  431 

sediments,  significance  of,  423 

shreds  in,  422 

significance  of  free  cells  in,  434 

specific  gravity  of,  421 

spermatozoa  in,  434 

total  solids  in,  421 

turbidity  of,  422 

.urate  sediment  in,  423 
Uterus,  449 

cancer  of,  450 

endometritis,  450 

erosions  of  cervix,  449 

fibro-myoma  of,  450 

lacerations  of  cervix,  449 

malpositions  of,  449 

prolapse  of,  449 
Uvula,  28 

VALGUS,  462 

Valve  areas,  171 

Valvular  heart  lesions,  210-256 


INDEX. 


•>79 


Valvular  lesions,  combined,  253 

Yaricocele,  447 

Varus,  462 

Vascular  phenomena,  87,  92 

phenomena  in  aortic  regurgita- 
tion,  230-234 

sounds,  182,  183 

tension,  108 
Vasomotor  disease,  519 
Veins,  abdominal,  365 

inspection  of,  88,  247 

pulsations  in  (see  Pulsation) 

sounds  in,  183 

thrombosis  of,  460 

varicose,  460 
Ventricle,  dilatation  of,  209 

hypertrophy  of,  206-208 
Ventricular  septum,  defects  of,  266 
Vertebra?,     cervical,    dislocation    of, 
32 

deviations  of,  33 

deviations  of,  due  to  habit  or  oc- 
cupation, 33 

deviations  of,  due  to  intracranial 
disease,  33 

deviations  of,  in  astigmatism,  33 

when  palpable,  368 
Vocal  fremitus,  167-169 

fremitus,  in  pleurisy  with  effu- 
sion, 345,  350 

fremitus,  in  pneumonia,  298,  299 

fremitus,  in  pneumothorax,  332 

fremitus,  in  pulmonary  tubercu- 
losis, 308,  311 

fremitus,  spoken,  168 

fremitus,    whispered,    167,    298, 

350 

Voice  sounds  (see  V ocal  fremitus) 
Vomiting,  in  gastric  cancer,  384 

in  gastric  ulcer,  385 

in  general  peritonitis,  373 


Vomiting,   in    intestinal  obstruction, 

403 

Vomitus,  "coffee-ground,"  384 
Vulva,  eczema  of,  448 

oedema  of,  448 

varicose  veins,  448 
Vulvo-vaginitis,  448 

WASTING  diseases,  depressed   fonta- 

nels  in,  7 

Weeping  sinew,  41 
Weight,  gain  in,  1 

in  infectious  fevers,  2 

in  insomnia,  2 

in  malnutrition, "2 

in  myxoedema,  1 

in  old  age,  2 

in  toxaemic  states,  2 

increased  after  wasting  diseases,  1 

increased  in  dropsy,  1 

loss  of,  2 

physiological  changes  in,  2 
Weil's  disease,  jaundice  in,  394 
Whooping-cough,  blood  in,  481 

oedema  of  eyelids  in,  14 
Widal  reaction  in  typhoid,  483 
Winking  reflex,  517 
Wrist,  enlargement  of  bones  in  pulmo- 
nary osteoarthropathy,  42,  43, 
47 

in  atrophic  arthritis,  47 
Wrist-drop  in  lead-poisoning,  36 
Wry-neck,  32 

X-RAY  in  diagnosis  of  Pott's  disease, 

495 

in  hypertrophic  arthritis,  501 
in  joint  examination,  489,  490- 

493,  494 

YELLOW  fever,  with  conjunctivitis,  14 
fever,  jaundice  of,  394 


Date  Due 


CAT.   NO.   23   233  PRINTED   IN    U.S.A. 


°°0  453  908 


Cabot . 

Physical  diagnosis 


WB200 
Cll6p 
1909 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


